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TRANSACTIONS
OF THE
AMERICAN
SURGICAL ASSOCIATION.
VOLUME THE NINETEENTH.
Edited by
RICHARD H. HARTE, M.D.,
RECORDER OF THE ASSOCIATION.
PRINTED FOR THE ASSOCIATION,
rOR SALE BY
WILLIAM J. DORNAN, PHILADELPHIA.
I 90 I .
Copyright, 1901, by RICHARD H. Harte, M.D., Recorder of the Association.
ID
I
m
DORNAN. PRINTER,
701-709 ARCH STREET.
PHILADELPHIA.
CONTENTS.
Officers of the Association ix
List of Presidents of the Association xi
Fellows of the Association ......... xiii
Honorary Fellows xxvii
Address of the President. The Recent Buffalo Investigations Regard-
ing the Nature of Cancer. By Roswell Park, M.D. . . . i
The Early Signs of Carcinoma of the Uterus. By Thomas S. Cul-
LEN, M.D 24
Brief Consideration of Cases of Cancer of the Breast Treated at the
Johns Hopkins Hospital Since 1889. By W. S. Halsted, M.D. . 26
Late Results of the Treatment of Inoperable Sarcoma with the Mixed
Toxins of Erysipelas and Bacillus Prodigiosus. By William B.
CoLEY, M.D 27
The Influence of Mental Depression on the Development of Malig-
nant Disease. By Joseph D. Bryant, M.D. . ... 43
The Cause of Cancer. By Thomas S. Cullen, M.D. . • • 57
The Clinical Value of Blood Examinations in Appendicitis : A Study
Based on the Examination of One Hundred and Eighteen Cases
in the German Hospital, Philadelphia. By J. C. Da Costa. Jr.,
M.D 60
The Blood Changes Induced by the Administration of Ether as an
Anaesthetic. By John Chalmers Da Costa, M.D., and Fred-
erick J. Kalteyer, M.D . . .72
Studies of the Blood in its Relation to Surgical Diagnosis. By R. C.
Cahot. M.D., J. C. Hubbard, M.D., and J. B. Blake, M.D. . 104
The Examination of the Blood in Relation to Surgery of Scientific but
Often of No Practical Value, and May Misguide the Surgeon. By
John B, Deaver, M.D 115
Blood Examinations as an Aid to Surgical Diagnosis. By Joseph C.
Bloodgood, M.D 122
IV CONTENTS.
PAGE
Fractures of the Pelvis from Violence Exerted Through the Long Axis
of the Femurs, Being a Comparative Study of the Relative Strength
of the Neck of the Femur and that of the Pelvis when the Violence
is Transmitted Through the Long Axis of the Former. By Oscar
H. Allis, M.D 145
On Pancreatitis. By A. W. Mayo Robson, F.R.C.S. . . .149
The Surgical Treatment of Chronic Ulcer of the Stomach. By A. W.
Mayo Robson, F.R.C.S 184
Exhibition of Methods of Medical Instruction in the Johns Hopkins
Medical School and Hospital . . . . . . . .216
Phlebitis Following Abdominal Operations. By Albert Vander
Veer, M.D 223
Traumatic Arterio-venous Aneurisms of the Subclavian Vessels, with
an Analytical Study of Fifteen Reported Cases, Including One
Operated. By Rudolph Matas, M.D 237
An Operation for the Radical Cure of Umbilical Hernia. By William
J. Mayo, A.M., M.D 296
Prevention and Cure of Post-operative Hernia. By James E Moore,
M.D 307
Fractures and Dislocations of the Spine. By S. H. Weeks, M.D. . 314
Radical Cure of Inguinal and Femoral Hernia, with a Report of
Eight Hundred and Forty-five Cases. By William B. Coley,
M.D. . 337
Treatment of Aortic Aneurisms by Means of Silver Wire and Elec
tricity ; with Report of Cases. By Leonard Freeman, M.D. . 359
Double Renal Calculus. By S. J. Mixter, M.D 377
A New Method of Closing the Wound in Thorough Removal of the
Breast. By S. J. Mixter, M.D 380
Resection of a Large Part of the Chest Wall for a Sarcoma ; Use of
Fell's Apparatus for Artificial Respiration ; Late Continuous Fever
Due to Staphylococcus Blood Infection ; Successful Use of the Anti-
streptococcic Serum ; Complete Recovery. By W. W. Keen, M.D.,
LL.D., F.R.C.S. (Hon.) 383
Artificial Respiration by Direct Intralaryngeal Intubation with a Modi-
fied O'Dwyer Tube and a New Graduated Air-pump in its .Applica-
tions to Medical and Surgical Practice. By Rudolph Matas, .M.D. 392
An Apparatus for Massive Infiltration Anaesthesia with Weak Anal-
gesic Solutions (Modified Schleich Method). By Rudolph Matas,
M.D 412
Two Cases of Vicious Circle After Cja^tro-enterostomy. By Theo-
dore A. McCraw, .M.D. 417
Anterior Dislocation of the Tibia Treated by Arlhrotomy. By John
B. Roberts, >LI) 441
CONTENTS,
PAGE
Giant Sacrococcygeal Tumors. An Account of One which Pursued
an Atrophic Course. By Charles A. Powers, M.D. . . . 444
Cicatricial Stricture of the CEsophagus. Gastrostomy, with Retro-
grade Dilatation of the Stricture by Rubber Tubes. By Henry R.
Wharton, M.D 45°
Movable Kidney : Its Cause and Treatment. By M. L. Harris, M.D. 457
Pneumotomy for Abscess of the Lung. With Exhibition of Patient.
By W. Joseph Hearn, M D., and W. J. Roe, M.D. . . .482
Excision of a Part of Three Ribs and a Portion of the Diaphragm for
Sarcoma. By C. B. Porter, M.D. 494
Cases of Laceration of the Spleen and of the Kidney, Followed by
Recovery After the Removal of the Injured Organ. By Samuel J.
Mixter, M.D 499
Subtrochanteric Osteotomy for the Deformity Following Hip Disease.
By E. H. Bradford, M.D . . 502
LIST OF ILLUSTRATIONS.
Diagrammatic Representation of Arterio-venous Communication (after
Excision of Clavicle), Matas, 251
Treatment of Umbilical Hernia, Ochsner, 303
Resection of the Chest Wall for Sarcoma, Keen (Figs. 1-4), 384-388.
Experimental Automatic Respiratory Apparatus, Matas, 409
Apparatus for Artificial Respiration in Surgical and Medical Practice
(latest model), Matas, 410
Rupture of the Spleen, Mixter, 499
LIST OF PLATES
PAGE
Blood Changes Induced by the Administration of Ether as an Anaes-
thetic, Da Costa and Kalteyer (Figs, i and 2) . . facing 100
Arterio-venous Aneurisms of the Subclavian Vessels, Matas facing 240
Operation for Radical Cure of Umbilical Hernia, Mayo (Figs, i to 4)
facing ici(y
Experimental Automatic Respiratory Apparatus, Matas (Figs, i and 2)
facing 409
Apparatus for Artificial Respiration in Surgical and Medical Practice
(latest model), Matas (Figs. 3 and 4) . . . . fa<^i"g 410
Apparatus for Rapid, Massive Infiltration Anaesthesia, Matas (Figs, i
and 2) facing 413
Anterior Dislocation of the Tibia Treated by Arthrotomy, Roberts
(Figs. I to 5) facing 441
Giant Sacrococcygeal Tumors, Powers (Figs, i to 9) . . facing 448
Pneumotomy for Abscess of Lung, Hearn and Roe . . facing 488
Excision of a Part of Three Ribs and a Portion of the Diaphragm for
Sarcoma, Porter (Figs, i to 4) . . . , . facing 496
OFFICERS OF THE ASSOCIATION,
Elected May, 1901.
PRESIDENT.
DE FOREST WILLARD, M.D.
VICE-PRESIDENTS.
ROBERT ABBE. M.D.
RUDOLPH MATAS, M.D.
SECRETARY.
DUDLEY p. ALLEN, M.D.,
278 Prospect Street, Cleveland.
TREASURER.
GEORGE RYERSON F'OWLER, M.D.,
302 Washington Avenue, Brooklyn.
RECORDER.
RICHARD H. HARTE, M.D.,
1503 Spruce Street, Philadelphia.
COUNCIL.
WILLIAM W. KEEN. M.D.
ROBERT F. WEIR, M.D.
ROSWELL PARK. M.D.
DE FOREST WILLARD, M.D., ^
DUDLEY P. ALLEN, M.D.. I
1- Ex-ojficto.
G. R. FOWLER, M.D., j "^
RICHARD H. HARTE, M.D., J
OFFICERS OF THE ASSOCIATION.
PUBLICATION COMMITTEE.
RECORDER, SECRETARY and TREASURER.
COMMITTEE ON ANNUAL MEETING.
SAMUEL J. MIXTER, M.D. B. FARQUHAR CURTIS. M.D.
PRESIDENT, SECRETARY, RECORDER and CHAIRMAN
COMMITTEE OF ARRANGEMENTS.
COMMITTEE ON STANDARD NOMENCLATURE AND STUDY OF TU.MORS.
ROSWELL PARK. M.D. J. C. WARREN, M.D.
W. S. HALSTED, M.D. F. S. DENNIS, M.D.
COMMITTEE ON ADVANCEMENT AND PROTECTION OF RESEARCH WORK.
ROSWELL PARK, M.D.
NICHOLAS SEXN, M.D.
HERBERT L. BURRELL, M.D.
W. W. KEEN, M.D.
Place of next Meeting — Albany, N. Y., June 3, 4 and 5, 1902.
COMMITTEE OF ARRANGEMENTS.
A. VANDER VEER, M.D.
W. G. MACDONALD, M.D.
R. B. BONTECOU, M.D.
LIST OF THE PRESIDENl'S
ASSOCIATION FROM THE TIME OF ITS INSTITUTION.
18S3
1884
1885
188^)
1887
1888
o.f SAMUEL DAVID GROSS, M.D., LL.D., D.C.L. Oxon.,
LL.D. Cantab., LL.D. Edin. — Founder of the Association.
EDWARD MOTT MOORE, M.D., LL D.
t WILLIAM THOMPSON BRIGGS, M.D.
t MOSES GUNN, A.M., M.D., LL.D. '
t HUNTER McGUIRE, M.D., LL.D.
t D. HAYES AGNEW, M.D., LL D.
DAVID WILLIAMS CHEEVER, M.D., LL.D.
1889 t DAVID W. YANDELL, M.D.
1890 t CLAUDIUS HENRY MASTIN, M.D., LL.D.
1891. PHINEAS SANBORN CONNER, M.D., LL.D.
NICHOLAS SENN, M.D., Ph.D., LL.D.
J. EWING MEARS, A.M., M.D.
FREDERIC SHEPARD DENNIS, M.D.
LOUIS McLANE TIFFANY, A.M. Cantab., M.D.
JOHN COLLINS WARREN, M.D., LL.D. (Jefferson),
Hon. F R.C.S. Eng.
THEODORE F. PREWITT, M.D.
WILLIAM W. KEEN, A.M., M.D., LL.D., Hon. F. R.C.S.
Eng.
ROBERT F. WEIR, M.D.
ROSWELL PARK, M.D.
DE FOREST WILL.ARD, A.M., M.D., Ph.D.
1892
•893
1894
1895
1896
1897
1808
i«99
1900
1901
t Deceased.
NOTICE.
This volume of Transactions contains the papers read before
the Association at the Meeting held May 7-9, 1901.
The Association assumes no responsibility for the statements and
opinions published in this volume.
FELLOWS
OF THE
AMERICAN SURGICAL ASSOCIATION,
MAY, 1901.
* Denotes Original Fellows.
ELECTED
1890. Abbe, Robert, M.D , Vi.e- President, 13 West Fiftieth Street,
New York. Surgeon to St. Luke's Hospital.
1894. Allen, Dudley P., A.M., M.D., Secretary, 278 Prospect
Street, Cleveland, Ohio. Professor of Surgery, Medical
Department Western Reserve University ; Visiting Surgeon,
Lakeside and Charity Hospitals; Consulting Surgeon to the
Cleveland City Hospital.
1890. Allis, Oscar Huntington, A.M., M.D., 1604 Spruce Street,
Philadelphia. Surgeon to the Presbyterian Hospital.
1901. Armstrong, George E., CM., M.D., 320 Mountain Street,
Montreal. Associate Professor of Clinical Surgery, McGill
University ; Surgeon to the Montreal General Hospital ;
Surgeon to the Western Hospital, Montreal.
1882. Barton, James M., A M., M.D., 1337 Spruce Street, Phila-
delphia. Surgeon to the Jtfferson Medical College Hos-
pital and to the Philadelphia Hospital.
1896. Baxter, George A., A.M., M.D., Chattanooga, Tennessee.
Professor of Surgery, Chattanooga Medical College.
1901. Bell, James, M.D., 873 Dorchester Street, Montreal.
Professor of Clinical Surgery, McGill University ; Surgeon
to the Royal Victoria Hospital.
XIV FELLOWS OF THE ASSOCIATION.
ELECTED
1900. Bevan, Arthur Dean, M.D., 100 State Street, Chicago.
Associate Professor of Surgery, Rush Medical College, Uni-
versity of Chicago; Surgeon Presb}terian Hospital.
1901. BiNNiE, B. F., M.B., CM. (Aberdeen), 12th and Wyandotte
Street, Kansas City, Mo. Professor of Surgical Pathology
and Clinical Surgery, Kansas City Medical College.
1 90 1. Bloodgood, Joseph C, B S., M.D., 923 North Charles Street,
Baltimore, Md. Associate in Surgery in the Johns Hopkins
University.
1882. Bontecou, Reed Brockway, M.D., 82 Fourth Street, Troy,
N. Y. Surgeon to the Marshall Infirmary.
1901. Bosher, Lewis C, M.D., 717 Franklin Sreet, Richmond,
Va. Professor of Surgery, Medical College of Virginia; Sur-
geon to the Old Dominion Hospital.
1890. Bradford, Edward Hickling, A.B., M.D., 133 Newbury
Street, Boston. Surgeon to the Children's and the Samari-
tan Hospitals ; Assistant Professor of Orthopaedic Surgery
in the Harvard University.
1900. Brewer, George Emerson, M.D., 68 West Forty-sixth Street,
New Yoik City. Junior Surgeon Roosevelt Hospital; Attend-
ing Surgeon City Hospital; Assistant Demonstrator of An-
atomy in College of Physicians and Surgeons (Columbia
University), New York.
*i88o. Brinton, John H., M.D., 1423 Spruce Street, Philadelphia.
Professor of the Practice of Surgery and of Clinical Surgery
in the Jefferson Medical College ; Surgeon to St. Joseph's
Hospital. Treasurer, 1884-85.
1895. Bryant, Joseph D , M.D., 54 West Thirty-sixth Street, New
York. Professor of Anatomy and of Operative and Clinical
Surgery, Bellevue Hospital Medical College ; Surgeon to
Bellevue and St. Vincent's Hospitals ; Consulting Surgeon
to Gouverneur Hospital, Hospital for Ruptured and Crippled,
St. Joseph's and Hackensack Hospitals, Asylum for Insane,
New York, etc.
1882. Bull, William Tillinghast, A.B., M.D., 35 West Thirty-
fifth Street, New York. Adjunct Professor of the Practice
of Surgery and of Clinical Surgery in the College of Physi-
cians and Surgeons, New York ; Surgeon to the New York
and Sf. Luke's Hospitals ; Consulting Surgeon to the Hos-
FELLOWS OF THE ASSOCIATION. XV
LECTED
pital for Ruptured and Crippled, and to the New York
Cancer Hospital.
1900. Bunts, Frank E., M.D.,Osborn Building, 275 Prospect Street,
Cleveland, Ohio. Professor Principles of Surgery and Clin-
ical Surgery in Medical College of Western Reserve Uni-
versity; Visiting Surgeon to St. Vincent's Charity Hospital;
Consulting Surgeon to Cleveland City and Lutheran Hos-
pitals.
1893. BuRRELL, Herbert Leslie, M.D. (Harvard), 22 Newbury
Street, Boston, Mass. Assistant Professor of Surgery in Har-
vard University ; Visiting Surgeon, Boston City Hospital ;
Visiting Surgeon, The Children's Hospital ; Consulting Sur-
geon, Carney Hospital and the Quincy Hospital. Secretary,
1895-1901.
1889. Cabot, Arthur Tracv, A.M., M.D., 3' Marlborough Street,
Boston, Mass. Surgeon to the Massachusetts General Hos-
pital.
1885. Carmalt, William H., A.M., M.D., 87 Elm Street, New
Haven, Conn. Professor of Surgery in Yale University ;
Surgeon to the New Haven Hospital. Vice-President,
1895.
1896. Carson, Norman Bruce, M.D., 209 North Jefferson Avenue,
St. Louis, Mo. Professor of Clinical Surgery in the St.
Louis Medical College ; Surgeon to the St. Louis and
Mullanphy Hospitals, and to the St. Vincent Insane Asy-
lum, etc.
1882. Cheever, David Williams, M.D.,LL.D., 557 Boylston Street,
Boston, Mass. Professor of Surgery (Emeritus) in Harvard
University ; Surgeon to the Boston City Hospital. Presi-
dent, 1888.
1896. Cole, Charles Knox, A.M , M.D., Helena, Montana. Sur-
geon to St. John's, St. Peter's, and County Hospitals.
1898. Coley, William B , M.D., 5 Park Avenue, New York.
Attending Surgeon to the New York Cancer Hospital ;
Assistant Surgeon to the Hospital for the Ruptured and
Crippled.
'i88o. Conner, Phineas Sanborn, M.D., LL.D., 159 West Ninth
Street, Cincinnati, Ohio. Professor of Surgery in the Medi-
XVI FELLOWS OF THE ASSOCIATION.
ELECTED
cal College of Ohio ; Professor of Surgery, Dartmouth
Medical College ; Surgeon to the Cincinnati and the Good
Samaritan Hospitals. President, 1891 ; Member of Council,
1883 and 1 895-1 900; Treasurer, 1885-91
1896. Curtis, Benjamin Farquhar, A.B., M.D., 7 East Forty-first
Street, New York. Professor of the Principles of Surgery
and Clinical Surgery, University and Bellevue Hospital
Medical College of New York ; Attending Surgeon to St.
Luke's and Bellevue Hospitals, and the General Memorial
Hospital for Treatment of Cancer and Allied Diseases ;
Consulting Surgeon to New York Orthopaedic Hospital and
Dispensary.
1896. Gushing, Havward Warren, A.B., M.D., 70 Commonwealth
Avenue, Boston, Mass. Junior Visiting Surgeon, Boston
City Hospital; Assistant Surgeon, Children's Hospital,
Boston.
1897. Da Costa, John Chalmers, M.D., 1629 Locust Street, Phila-
delphia, Pa. Clinical Professor of Surgery, Jefferson Medi-
cal College ; Surgeon to the Philadelphia and the Phoenix-
ville Hospitals.
1883. Dandridge, Nathaniel Pendleton, M.D., 422 Broadway,
Cincinnati, Ohio. Professor of Practice of Surgery and of
Clinical Surgery in the M ami Medical College, Cincinnati.
Treasurer, 1894-96.
1892. Deaver, John B., M D., 1634 Walnut Street, Philadelphia.
Surgeon to the German Hospital, Philadelphia.
1882. Dennis, Frederic Shepard, M.D.,F.R C.S. Eng., 542 Mad-
ison Avenue, New York. Professor of Clinical Surgery,
Cornell University, New York City ; Visiting Surgeon to the
Bellevue and St. Vincent's Hospitals; Consulting Surgeon
to St. Joseph's Hospital, Yonkers, and Montefiore Home,
New York City. President, 1894; Vice-President, 1887;
Member of Council, 1889.
1899. Dunn, James H., M.D., 337 Oak Grove Street, Minneapolis,
Minn. Professor of Practice of Surgery, Medical Depart-
ment, University of Minnesota.
1 901. Eliot, Ellsworth, Jr., M.D., 48 West Thirty-Sixth Street,
New York. Clinical Lecturer and Demonstrator of Surgery,
FELLOWS OF THE ASSOCIATION. XVll
LECTED
College of Physicians and Surgeons, New York ; Surgeon to
the Presbyterian Hospital.
1S93. Elliot, John Wheelock, A.M., M.D. (Harvard), 124 Bea-
con Street, Boston. Surgeon to Massachusetts General Hos-
pital.
1896. EsTES, William Lawrence, A.M., M.D., South Bethlehem,
Penna. Director and Surgeon-in-Chief of St. Luke's Hos-
pital ; Lecturer on Hygiene at Lehigh University.
1898. Eve, Duncan, A.M., M.D., 700 Church Street, Nashville,
Tenn. Professor of Surgery and Clinical Surgery, Medical
Department Vanderbilt University ; Surgeon to the Nashville
City Hospital.
1883. Fencer, Christian, M.D., 269 La Salle Avenue, Chicago.
Professor of Clinical Surgery, Rush Medical College ; Pro-
fessor of Clinical Surgery in the Northwestern University-
Medical School and the Chicago Polyclinic ; Surgeon to
Emergency, German, Mercy, and Norwegian Hospitals.
Vice- F resident, 1895.
1901. Ferguson, Alex. Hugh, CM., M.D., 452 East Forty-Ninth
Street, Chicago. Professor of Clinical Surgery in the Medi-
cal Department of the University of the State of Illinois ;
Professor of Surgery in the Post-Graduate Medical School of
Chicago; Surgeon in-Chief of the Chicago Hospital; Sur-
geon to Cook County Hospital for the Insane ; Consulting
Surgeon to Provident Hospital.
1899 Finney, John T., M.D., 1300 Eutaw Place, Baltimore,
Md. Associate Professor of Surgery, Johns Hopkins Uni-
versity.
1882. Forbes, William Smith, M.D., 901 Pine Street, Philadelphia.
Professor of Anatomy in the Jefferson Medical College of
Philadelphia.
1 89 1. Fowler, George Ryerson, M.D., Treasurer, 302 Washing-
ton Avenue, Borough of Brooklyn, New York City. Pro-
fessor of Surgery, Ncat York Polyclinic ; Examiner in Sur-
gery, Medical Examining Board of Regents, University
State of New York ; Surgeon to the Methodist Episcopal,
German, and Brooklyn Hospitals; Consulting Surgeon to
St. Mary's and Norwegian Relief (E.D.) Hospitals.
Am Surg B
XVlll FELLOWS OF THE ASSOCIATION.
BLECTBD
1898. Freeman, Leonard, B.S., M.D., California Building, Denver,
Col. Professor of Surgery, Gross Medical College ; Surgeon
to the Arapahoe County Hospital and to St. Anthony's
Hospital.
1 89 1. Gaston, James McFadden, A.B., M.D., 421 Capitol Avenue,
Atlanta, Georgia. Professor of Surgery in Southern Medi-
cal College. Vice-President, 1897.
1882. Gay, George Washington, A.M., M.D., 665 Boylston Street,
Boston, Mass. Senior Surgeon to the Boston City Hospital;
Clinical Instructor in Surgery in Harvard University.
Member of Council, 1882.
1892. Gerrish, Frederic Henry, A.M., M.D., 675 Congress Street,
Portland, Maine. Consulting Surgeon, Maine General
Hospital ; Professor of Anatomy in Medical Department of
Bowdoin College.
1890. Gerster, Arpad G., M.D., Chir. D., 34 East Seventy-fifth
Street, New York. Professor of Surgery in the New York
Polyclinic ; Surgeon to the German and Mount Sinai Hospi-
tals.
1892. Halsted, William Stewart, B.A., M.D., 1201 Eutaw Place,
Baltimore, Maryland. Surgeon to Johns Hopkins Hospital.
1898. Harrington, Francis B., A.B. (Tuft's College), M.D.
(Harvard College), 201 Beacon Street, Boston, Mass. Sur-
geon to Massachusetts General Hospital.
1901. Harris, Malcolm L., M.D., 100 State Street, Chicago, 111.
Professor of Surgery Chicago Polyclinic ; Attending Surgeon
Alexian Brothers' Hospital, St. Luke's Hospital, and Maurice
Porter Hospital for Children.
1895. Harte, Richard H., M.D., Recorder, 1503 Spruce Street,
Philadelphia. Surgeon to the Pennsylvania and Episcopal
Hospitals ; Consulting Surgeon, St. Mary's, St. Timothy's,
and Bryn Mawr Hospitals.
1898. Hearn, W. Joseph, M.D. , 11 20 Walnut Street, Philadelphia.
Clinical Professor of Surgery, Jefferson Medical College ;
Visiting Surgeon to the Philadelphia Hospital ; Consulting
Surgeon to the Phoenixville General Hospital.
1889. Homans, John, A.B., M.D., 164 Beacon Street, Boston.
Surgeon to the Massachusetts General Hospital.
FELLOWS OF THE ASSOCIATION. XIX
ELECTED
1899. HoRWiTZ, Orville, M.D., 1721 Walnut Street, Philadelphia,
Clinical Professor of Genito-Urinary Diseases, Jefferson
Medical College ; Surgeon to the Philadelphia Hospital ;
Consulting Surgeon to State Hospital for Insane and Hayes
Mechanics' Home.
1901. Huntington, Thomas W., A.B., M.D., 406 Sutter Street,
San Francisco, California. Professor of Clinical and Opera-
tive Surgery, Medical Department University of California;
Visiting Surgeon to the City and County Hospital, San Fran-
cisco; Consulting Surgeon St. Luke's Hospital, San Francisco.
1901. Jacobson, Nathan, M.D., 430 South Salina Street, Syracuse,
N.Y. Professor of Clinical Surgery, College of Medicine,
Syracuse University ; Surgeon to St. Joseph's Hospital,
1 90 1. Johnson, Alexander B., M,D., 12 East Fifty-Eighth Street,
New York. Professor of Clinical Surgery, Cornell University
Medical College ; Attending Surgeon to New York Hos-
pital.
1896. Johnston, George Ben, M.D., 207 East Grace Street, Rich-
m.ond, Va. Professor of the Practice of Surgery and of
Clinical Surgery in the Medical College of Virginia; Sur-
geon to the Old Dominion Hospital, and Consulting Surgeon
to the Richmond City Free Dispensary.
1901. Jonas, A. F., M.D., Continental Block, Omaha, Nebraska.
Professor of Surgery, Omaha Medical College ; Surgeon to
the Methodist Episcopal Hospital and to the Douglas County
Hospital.
1899. Kammerer, Frederick, M.D., 51 East Sixty-sixth Street, New
York City. Professor of Clinical Surgery, Cornell Medical
College; Surgeon to the German and St. Francis' Hospitals,
New York.
*i88o Keen, William Williams, A.M.,M.D., LL.D., Hon. F.R.C.S.
Eng., 1729 Chestnut Street, Philadelphia. Professor of
the Principles of Surgery and of Clinical Surgery in the
Jefferson Medical College; Surgeon to the Jefferson Medical
College Hospital and to the Orthopaedic Hospital and In-
firmary for Nervous Diseases ; Consulting Surgeon to the
Woman's and St. Agnes' Hospitals ; Membre Correspondant
KX FELLOWS OF THE ASSOCIATION.
BLECTED
Etrange de la Societe de Chirurgie de Paris; Membre Hon-
oraire de la Societe Beige de Chirurgie. Presidetit, 1898;
Vice-President, 1892; Member of Council, 1 899-1 901.
1901. La Garde, Louis A., M.D., United States Soldiers' Home,
Washington, D.C. Professor of Military Surgery, New York
University and Bellevue Hospital Medical College ; Major
and Surgeon United States Army.
1901. Le Conte, Robert G., A.B., M.D., 348 South Sixteenth
Street, Pniladelphia. Surgeon to the Pennsylvania, the Chil-
dren's, and the Bryn Mawr Hospitals.
1890. Lane, Levi Cooper, A.M., M.D., M.R.C.S. Eng.,LL.D., San
Francisco, Cal. Professor of Surgery in the Cooper Medi-
cal College, San Francisco. Vice-President, 1891.
1889. Lange, Frederick E., M.D., 691 Lexington Avenue, New
York.
1901. McArthur, L. L., M.D., 4415 Drexel Building Chicago, 111.
Professor of Clinical Surgery, Post-Graduate Medical School ;
Assistant Professor of Clinical Surgery, Rush Medical Col-
lege ; Surgeon to St. Luke's and Michael Reese Hospitals.
1896. McCosH, Andrew J., B.A., M.D., 16 East Fifty-fourth Street,
New York, Surgeon to the Presbyterian Hospital ; Clinical
Lecturer on Surgery, College of Physicians and Surgeons.
1882. McGraw, Theodore A., M.D., 107 West Fort Street, Detroit,
Michigan. Professor of Surgery in the Detroit Medical
College ; Surgeon to Sr. Mary's and the Harper Hospitals.
Vice-President, 1896.
1901. Macdonald, Willis G., M.D., 27 Eagle Street, Albany, New
York.
1899. Markoe, Francis H., M.D., 15 East Forty-ninth Street, New
York. Professor of Clinical Surgery, Medical Department
Columbia University, New York City; Attending Surgeon,
St. Luke's and New York Hospitals; Consulting Surgeon,
Orthopaedic Hospital.
■1880. Marks, Solon, M.D., 136 Wisconsin Street, Milwaukee, Wis.
Surgeon to St. Mary's Hospital. Vice-Preside?it, 1898.
1898. Martin, Edward, M.D., 415 South Fifteenth Street, Phila-
delphia. Clinical Professor of Surgery, University of Penn-
FELLOWS OF THE ASSOCIATION. XXI
:lkcted
sylvania; Clinical Professor of Surgery, Woman's Medical
College, Philadelphia; Surgeon to Philadelphia, St. Agnes',
and Howard Hospitals.
1887. Mastin, William McDowell, M.D., Northwest corner of
Joachim and Conti Streets, Mobile, Ala. Surgeon to the
Mobile City Hospital.
1895. Matas, Rudolph, M.D., Vice-President, 2255 St. Charles Ave-
nue, New Orleans, La. Professor of Surgery, Medical De-
partment Tulane University ; Professor of Clinical Surgery,
New Orleans Polyclinic ; Surgeon to Charity Hospital ; Con-
sulting Surgeon to the Eye, Ear, Nose, and Throat Hospital.
1899. Mavo, William J., A.M., M.D., 427 West College Street,
Rochester, Minn. Surgeon to St. Mary's Hospital.
= 1880. Mears, J. EwiNG, A.M., M.D., 1429 Walnut Street, Philadel-
phia. President, 1893; Recorder, _i?>Si-()t,.
1901. Meyer,' Willy, M.D., 700 Madison Avenue, New York.
Professor of Surgery in the New Y9rk Post-Graduate Medi-
cal School and Hospital ; Attending Surgeon to the German
and New York Skin and Cancer Hospitals ; Consulting Sur-
geon to the New York Infirmary for Women and Children.
1893. MixTER, Samuel Jason, S.B. (Massachusetts Institute of
Technology), M.D. (Harvard), 180 Marlborough Street,
Boston. Surgeon to Massachusetts General Hospital and to
Carney Hospital ; Consulting Surgeon to the Massachusetts
Charity Eye and Ear Infirmary; Instructor in Surgery in
the Harvard University.
1896. Monks, George Howard, A.B. (Harvard), M.D. (Harvard),
M.R.C.S. Eng., 67 Marlborough Street, Boston. Surgeon
to Carney Hospital ; Assistant Visiting Surgeon, Boston City
Hospital ; Instructor in Clinical and Assistant in Operative
Surgery, Harvard Medical School ; .Instructor in Surgical
Pathology, Harvard Dental School.
1895. Moore, James E., M.D., 802 Dayton Building, Minneapolis,
Minn. Professor of Clinical Surgery, University of Minne-
sota ; Surgeon to St. Barnabas' and Northwestern Hospitals ;
Consulting Surgeon to St. Mary's and City Hospitals.
^1880. Morton, Thomas George, M.D., 1421 Chestnut Street,
Philadelphia. Surgeon to the Pennsylvania and Consulting
Surgeon to the Orthopaedic and Jewish Hospitals.
XXII FELLOWS OF THE ASSOCIATION.
BLBCTED
1898. Morton, Thomas S. K., M.D,, 1506 Locust Street, Phila-
delphia. Professor of Surgery, Philadelphia Polyclinic and
College for Graduates in Medicine; Surgeon to the Out-
Patient Department of the Pennsylvania Hospital ; Consult-
ing Surgeon to the Woman's Hospital.
1900. MuNRO, John C, M.D., 173 Beacon Street, Boston. Instructor
in Surgery, Harvard ; Professor of Surgery, Tuft's College
Dental School; Assistant Visiting Surgeon, Boston City
Hospital.
1898. Murray, Francis W., M.D., 32 West Thirty-ninth Street,
New York City. Professor of Clinical Surgery in Cornell
University Medical College ; Surgeon to the New York and
St. Luke's Hospitals.
1882. Nancrede, Charles Beylard, A.M. (University of Penn-
sylvania), M.D., LL.D. (Jefferson), Southwest corner Thayer
Street and South University Avenue, Ann Arbor, Mich.
Professor of Surgery in the University of Michigan. Vice-
Preside?tf, 1889 and 1899.
1900. OcHSNER, A. J., B.S., F.R.M.S., M.D. (Eng.), 710 Sedgwick
Street, Chicago. Professor of Clinical Surgery, College of
Physicians and Surgeons ; Surgeon-in-Chief of Augustana
and St. Mary's Hospitals.
1900. Oliver, J. C, M.D., Berkshire Building, 628 Elm Street,
Cincinnati, Ohio. Professor of Descriptive Anatomy,
Miami Medical College ; Surgeon Cincinnati, Presbyterian,
and Christ Hospitals.
1S82. Owens, John E., M.D., 1806 Michigan Avenue, Chicago.
Professor of Principles and Practice of Surgery and Clinical
Surgery in the Chicago Medical College ; Surgeon to St.
Luke's Hospital. Vice-President , 1900.
1899. Parham, Frederick William, M.D., 1429 Seventh Street, New
Orleans, La, Professor of General Clinical and Operative
Surgery on the Cadaver, New Orleans Polyclinic; Surgeon,
Charity Hospital ; Consulting Surgeon, Eye, Ear, Nose, and
Throat Hospital.
1885. Park, Roswell, A.M., M.D., 510 Delaware Avenue, Buffalo,
N. Y. Professor of Surgery in the Medical Department of
FELLOWS OF THE ASSOCIATION. XXIU
ILBCTED
the University of Buffalo ; Surgeon to the Buffalo General
Hospital ; Consulting Surgeon to the Fitch Accident Hos-
pital. President, 1900; Vice-President, 1893; Member of
Council, 1893-94, 1 90 1.
1896. Parkhill, Clayton, M.D., 245-46 Equitable Building, Den-
ver, Col. Dean of the Colorado School of Medicine, Medi-
cal Department of the University of Colorado, and Professor
of the Principles and Practice of Surgery and Clinical Sur-
gery in the same ; Professor of Surgery in Gross Medical
College, Denver; Surgeon to St. Luke's and the Arapahoe
County Hospitals, Denver; Surgeon-in Chief to the Citizens'
Hospital, Aspen, Col. ; Consulting Surgeon to the State
Hospital for the Insane, Pueblo, Col. ; Surgeon-General of
the National Guard of Colorado. Vice-President, 1900.
1893. Parmenter, John, M.D., 519 Franklin Street, Buffalo, N. Y.
Professor of Anatomy and Clinical Surgery in the Medical
Department of the University of Buffalo ; Surgeon to the
Sisters of Charity, Erie County, Fitch, Children's, and
Emergency Hospitals; Assistant Surgeon, Buffalo General
Hospital.
1889. PiLCHER, Lewis S., A.M., M.D., LL.D. (Dickinson), 145
Gates Avenue, Brooklyn, N.Y. Professor of Clinical Surgery
in the Post- Graduate Medical School, New York ; Surgeon
to the Methodist Episcopal Hospital. Vice-President, 1893.
1887. Porter, Charles Burnham, A.M., M.D. (Harvard), 5 Arling-
ton Street, Boston, Mass, Professor of Clinical Surgery in
Harvard University ; Surgeon to the Massachusetts General
Hospital. Vice-President, 1892.
1882. Porter, William Gibbs, M.D., 11 18 Spruce Street, Philadel-
phia, Surgeon to the Presbyterian Hospital.
1896, Powers, Charles A., M.D., Fourteenth and Stout Streets,
Denver, Col. Professor of Surgery in the University of
Denver, and Surgeon to the Arapahoe County Hospital and
to St. L'jke's Hospital.
1882. Prewitt, Theodore F., M.D., 3101 Pine Street, St. Louis,
Mo, Professor of the Principles of Surgery in the Medical
Department of Washington University ; Surgeon to St. John's
Hospital. President, 1897; Vice-President, 1886; Metnber
of Council, 1894-96.
XXIV FELLOWS OF THE ASSOCIATION.
ELECTED
1886. Ransohoff, Joseph, M.D., F.R.C.S. Eng., 706 Walnut
Street, Cincinnati, Ohio. Professor of Anatomy in the
Medical College of Ohio ; Surgeon to the Cincinnati and
the Good Samaritan Hospitals.
1887. Richardson, Maurice Howe, A.B., M.D., 224 Beacon Street,
Boston, Mass. Surgeon to the Massachusetts General Hos-
pital; Assistant Professor of Clinical Surgery in Harvard
University. Vice-President, 1897; Secretary, 1894-96.
1901. RixFORD, Emmet, B.S., M.D., 1400 Van Ness Avenue, San
P'rancisco, Cal. Professor of Surgery in Cooper Medical
College ; Surgeon to the City, County, and Lane Hospitals.
1882. Roberts, John B., A.M., M.D., 1627 Walnut Street, Phila-
delphia. Professor of Anatomy and Surgery in the Phila-
delphia Polyclinic ; Surgeon to the Methodist and Jewish
Hospitals. Vice President, 1888 and 1894; Treasurer,
1892-93.
1S98. Rodman, William L., A.M., M.D., 1626 Spruce Street,
Philadelphia. Professor of the Principles of Surgery and
Clinical Surgery in the Medico-Chirurgical College, Phila-
delphia; Professor of the Principles and Practice of Surgery
and Clinical Surgery in the Woman's Medical College,
Philadelphia.
1882. RusHMORE, John Dikeman, M.D., 129 Montague Street,
Brooklyn, N, Y. Professor of Surgery in the Long Island
College Hospital ; Surgeon to the Brooklyn, St. Peter's,
and the Eye and Ear Hospitals.
1882. Senn, Nicholas, M.D., Ph.D., LL.D. (Jefferson), 532 Dear-
born Avenue, Chicago, 111. Professor of the Principles of
Surgery and Clinical Surgery in Rush Medical College;
Surgeon to Presbyterian Hospital ; Surgeon-in-Chief to St.
Joseph's Hospital. President, 1892; Me?nber of Council, i^<)'j.
1895. SoucHON, Edmond, M.D., 135 Baronne Street, New Orleans,
La. Professor of Anatomy and of Clinical Surgery, Tulane
University ; Surgeon to Charity Hospital ; Consulting Sur-
geon to the Eye, Ear, Nose, and Throat Hospital. Vice-
President, 1899.
1901. Taylor, William J., M.D., 1825 Pine Street, Philadelphia.
Surgeon to the Orthopaedic Hospital and Infirmary for
FELLOWS OF THE ASSOCIATION. XXV
LBCTED
Nervous Diseases, and to St. Agnes' Hospital ; Consulting
Surgeon to the West Philadelphia Hospital for Women.
1885. Thompson, J. Ford, M.D., 1401 H Street, N. W., Washing-
ton, D. C. Professor of Surgery in tl e National Medical
College ; Surgeon to the Garfield Memorial and the Chil-
dren's Hospitals.
1882. Thomson, William, M.D., 1426 Walnut Street, Philadelphia.
Emeritus Professor of Ophthalmology in the Jefferson Med-
ical College.
18S2. Tiffany, Louis McLane, A.M. (Cantab.), M.D., 831 Park
Avenue, Baltimore, Md. Professor of Surgery in the Uni-
versity of Maryland ; Surgeon to the University Hospital.
President, 1895; Mejnber of Council, 1885-89, and 1896-7.
1882. Vander Veer, Albert, A.M., M.D., Ph.E)., 28 Eagle Street,
Albany, N. V". Dean of Albany Medical College; Profes-
sor of Didactic Abdominal Surgery and of Clinical Sur-
gery in the Albany Medical College; Consulting Surgeon to
St. Peter's Hospital ; Attending Surgeon to the Albany
Hospital. Vice-President, 1898.
1891. Walker, Edward W., M.D., 96 West Eighth Street, Cin-
cinnati, Ohio. Professor of Surgery, Miami Medical
College.
1882. Warren, John Collins, M.D., LL.D. (Jefferson), Hon.
F.R.C.S. Eng., 58 Beacon Street, Boston, Mass. Professor
of Surgery in Harvard University ; Surgeon to the Massachu-
setts General Hospital. President, 1896; Vice-President,
1890; Member of Council, 1897.
1896. Watson, Francis Sedgwick, A.B., M.D., 92 Marlborough
Street, Boston. Surgeon to the Boston City Hospital ; In-
structor in Genito-Urinary Surgery, Harvard Medical
School.
1889. Weeks, Stephen H., M.D., 662 Congress Street, Portland,
Maine. Professor of Surgery in the Medical School of
Maine ; Surgeon to Maine General Hospital. Member of
Council, 1893.
1889. Weir, Robert F., M.D., 11 East Fifty-fourth Street, New
York. Professor of Surgery in the College of Ph}sicians
XXVI FELLOWS OF THE ASSOCIATION.
ELECTED
and Surgeons, Columbia University ; Surgeon to the Roose-
velt Hospital. President, 1899. Member of Cotincil, 1893-
1896 and 1901.
1892. Wharton, Henry R., A.M., M.D., 1725 Spruce Street,
Philadelphia. Surgeon to the Presbyterian, Children's, and
Methodist Hospitals.
1882. White, J. William, M.U., Ph.D., 1810 South Rittenhouse
Square, Philadelphia. John Rhea Barton Professor of Sur-
gery in the University of Pennsylvania.
1 89 1. Wight, Jarvis Sherman, A.M., M.D., LL.D., 30 Schermer-
horn Street, Brooklyn, N. Y. Professor of Operative and
Clinical Surgery, Long Island College Hospital ; Surgeon to
Long Island College Hospital ; Consulting Surgeon to St.
Mary's Hospital.
1882. WiLLARD, De Forest, A.M., M.D. (Univ. of Pa.), Ph.D.,
President, 1818 Chestnut Street, Philadelphia. Clinical
Professor of Orthopedic Surgery in the University of Penn-
sylvania; Surgeon to the Presbyterian Hospital; Consulting
Surgeon to the Hospital for the Chronic Insane of Pennsyl-
vania, and to the New Jersey Training School. Recorder,
1893-1900.
1901. WoLSEY, George, M.D., 117 East Thirty-sixth Street, New
York City. Professor of Anatomy and Clinical Surgery,
Cornell University; Surgeon to Bellevue Hospital.
HONORARY FELLOWS.
ELECTED
1885. Annandale, Thomas, M.R.C.S. Eng., M.D. Edin., 34
Charlotte Square, Edinburgh, Scotland. Regius Professor
of Clinical Surgery in the University of Edinburgh.
1894. VON Bergmann, Prof. Dr. Ernst, Geh. Med. Rath., Klin.
Institut fiir Chirurgie, Berlin, Germany.
1891. Bryant, Thomas, Esq., F.R.C.S. Eng., 65 Grosvenor Street,
Grosvenor Square, W., London.
1891. Chiene, John, F.R.C.S. Edin., M.D. Edin., 26 Charlotte
Square, Edinburgh, Scotland. Professor of Surgery in
the University of Edinburgh.
1885. CzERNY, Prof. Dr. Vincent, 25 Sophien Strasse, Heidel-
berg, Germany. Professor of Surgery in the University
of Heidelberg.
1885. voN EsMARCH, Prof. Dr. Friedrich, 2 Hospitalbcrg, Kiel,
Schleswig-Holstein, Germany. Professor of Surgery in the
University of Kiel.
1893. Gussenbauer, Prof. Dr. Carl, ix. Ferstelgasse, Vienna.
Imperial and Royal Professor of Surgery and Chief of
the Second Surgical Clinic and of the Surgical Institute.
1891. Harrison, Reginald, Esq., F.R.C.S. Eng., 6 Lower Berk-
eley Street, Portman Square, W., London.
1890. Horsley, Victor Alexander Haden, F.R.C.S. Eng., 25
Cavendish Square, W., London.
1883. Horwitz, p. J., M.D., 1919 Walnut Street, Medical Director
U. S. Navy (Retired), Philadelphia.
1894. Kocher, Prof. Dr. Theodor, Professor of Surgery, Univer-
sity of Berne, Villette 25, Berne, Switzerland.
1885. Lister, Lord Joseph, F.R.C.S. Eng., D.C.L., LL.D., 12
Park Crescent, London, N. W. Professor of Clinical Sur-
gery in King's College.
XXVIU HONORARY FELLOWS.
ELECTED
1886. MacCormac, Sir William, Bart., F.R.C.S. England and
Ireland, 13 Harley Street, London, W. Surgeon to St.
Thomas' Hospital.
1894. Macewen, William, M.D,, Mast. Surg., 3 Woodside Cres-
cent, Glasgow, Scotland.
*iS8o. Moore, Edward Mott, M.D., LL.D., 74 South Fitzhugh
Street, Rochester, N. Y. Surgeon to St. Mary's Hospital.
President, 1884.
1894. ScHEDE, Prof. Dr., Geh, Med. Rath., Director of Surgery,
University Clinic, Bonn, Germany.
1882. Smith, Stephen, A.M., M.D., LL.D., 574 Madison Avenue,
New York. Professor of Clinical Surgery in the University
Medical College of New York ; Surgeon to the Bellevue
and the St. Vincent's Hospitals. Vice-Presidetit, 1890.
1896. Terrier, Dr. Felix, 3 Rue de Copenhague, Paris. Professor
of Operative Surgery in the Faculty of Medicine of Paris ;
Surgeon to the Hopital Bichat.
* Original Fellow.
ADDRESS OF THE PRESIDENT.
THE RECENT BUFFALO INVESTIGATIONS RE-
GARDING THE NATURE OF CANCER.
By ROSWELL park, M.D.,
BUFFALO.
At the risk of tedium on your part I have^ ventured to select
as the subject of my address to you a topic upon which I have
been repeatedly heard during the past few years. This subject
of cancer has been for the pathologist the mystery of ages, and
continues to be the subject of active and profound study in all
quarters of the world, with now a promising hope of solution.
It would appear to be about the only local disease concerning
which there is still much of the uncertain and the unknown.
Diseases like scarlatina and syphilis, for instance, for which we
readily acknowledge acontagium vivum, are wide-spread, and in
no sense localized among the tissues; but the more one studies
cancer the more he becomes convinced that in its inception it is
purely local, and that the process of generalization is relatively
slow, save in certain rare instances. The older views about the
constitutional nature of the disease then may be set aside as
absolutely untenable, and we have nothing left to do now except
to consider it in its thus limited relations.
Pathologists who study it purely from the dead-house point
of view have confronted some of the greatest problems which it
has to offer, but have also missed some of its most important
aspects. On the other hand, the operating surgeon, who sees
in this mystery only the question of how far he may go with
the scalpel, misses also the fundamental theories of its origin
Am Surg i
2 PARK,
and the consideration of its etiology, upon which its whole suc-
cessful therapy must be based. Only by a combination of ante-
mortem and post-mortem studies can its nature be solved.
Microscopical sections alone may well arouse the numerous
hypotheses which are now in vogue as to the peculiar behavior
of cells and their reactions. But the clinician who is to study
the disease in its various phases may well criticise every
theory which ascribes cancer to purely intrinsic causes, even
though he be forced to acknowledge that he can not abso-
lutely demonstrate an extrinsic cause. Nevertheless, so much
has been done in the past few years that I for one have not
hesitated to avow myself a firm believer in the later teaching as
to the infectious nature of the disease, a theory, indeed, which I
have held to and taught for nearly fifteen years.
The parasites of cancer, be their nature what it may, are in
all probability polymorphic in extreme degree, and masquerade
under many forms, changing with their different stages of repro-
duction. So much of the personal equation enters into their
consideration and investigation that one must know an indi-
vidual and his methods before one knows exactly what estimate
to place upon his work and the weight to be attached to his
views. Take the work, for instance, of Borrel.' In 1892 he
published a monograph on the cellular evolution and parasitism
of epithelioma, in which he claimed that for four years he had
continuously and carefully studied the subject, and convinced
himself that there was no doubt about the parasitic feature of
these cases ; he claimed priority in the establishment of para-
sitism for Malassez.^ Borrel, like most French investigators, is
attached firmly to the parasitic hypothesis, and is of the belief
that the parasites in question are protozoa — i. e., are of animal
origin. In the plates which he published nine years ago there
may be seen the same peculiar appearances which most other
observers since his time have noted. In this connection one
may say that the most striking feature of all these studies, as one
compares the plates of various writers, is the fact that they all
' Evolution Cellulaire et Parasitism dans rEpithelioma, 1892.
^ Archiv. de Med. Exp., 1890, 2.
ADDRESS OF THE PRESIDENT. 3
agree as to the extraneous nature of certain cells which they
picture in various stages of cell division or reproduction, though
they nearly all differ in the peculiar interpretation of those phe-
nomena which they illustrate, differing as well in names as in
classification of the parasites, differing even in the kingdom to
which they assign them — i. e., animal or vegetable. It is most
suggestive in one regard, though somewhat disturbing in an-
other, to see practically the same parasitic forms described and
figured by an Italian writer as showing the presence of blasto-
mycetcX, while the French would call them protozoa, and most
of the German scholars would indicate them as mere products
of cell degeneration. This only illustrates, however, that to a
considerable extent, at least, the differences which appear so
great between different observers are merely differences of in-
terpretation. I do not see how one can stucly the various illus-
trations of this subject, still less the actual sections, without
being firmly of the opinion that parasitic forms are certainly
present, although he be absolutely in the dark as to their
minute nature, just as no man can come long in contact with
the clinical features of the disease without feeling that cancer
must be considered as an expression of infection of some kind,
without necessarily committing himself as to the minute nature
of the infectious element.
Let me here repeat the essential feature of an argument which
I brought before this Association in 1898 with regard to the
infectious nature of cancer. I have found that the length of
time over which this infection, if it be such, may extend, as
well as the period of incubation, are in many cases the principal
arguments which the opponents of this view advance against its
accuracy. Such argument as this, however, must fail from what
we already know of other infections. For instance, there are
infections which kill within a few hours from the appearance of
their first lesions, such, for instance, as bubonic plague, cholera,
etc. These constitute the most acute and disturbing type of
their kind. The time limit of others is measured by days, as,
for instance, in the case of tetanus, variola, pneumonia, and
meningitis. In yet others the course of the disease is only run
4 PARK,
within a few weeks, as in the case of typhoid fever. Tubercu-
losis and actinomycosis, again, run their course in a few months,
while in the case of syphilis and leprosy ordinarily the time in
which they kill by their own ravages is measured only in years.
No violence, then, is done to the general acceptance of the
theory of infection if we suppose that cancer is a disease whose
duration of infection may extend anywhere from weeks to
years.
There is no other disease which is characterized by metastasis
in which the pathologists decline to see evidences of parasitism.
When one considers the more acute expressions of metastatic
infection which he may see in surgical and puerperal sepsis, for
example, or the slower, seen especially in tuberculosis, they all
convey the same meaning to the careful student — i. e., they im-
ply that some infectious element has been transported from one
part of the body to another, there to set up disturbance similar
to that existing at the point of departure. Why should this ex-
planation be so acceptable in the cases of all other diseases and
so difficult of acceptance in the case of cancer? For myself, as
I have often remarked, every metastasis of cancer has the form
and significance of an inoculation experiment only performed
under the most favorable because natural conditions.
The primary question after all is the general one of parasitism.
Are not parasites at fault ? It has not yet been reduced to a
question of just which parasite. However, if analogy assists one
at all, he must not forget that there are numerous organisms
which may produce pus formation, and these belong not alone
to one kingdom. Why then may it not be so with cancer, that
not one organism alone but perhaps numerous forms are at
fault? In my opinion it may and probably will be found that
cancer is not a question of any single organism, possibly not
even of a single class.
Roger Williams, though acknowledging its inoculability, has
very little faith in the transmission of cancer from one human
being to another, even by contact, and he quotes Demarquay,
who collected 134 cases of cancer of the penis, whereas in only
one instance was the wife affected with uterine cancer.
ADDRESS OF THE PRESIDENT. 5
With regard to its inoculability, he acknowledges that the
evidence is so weighty as to be practically conclusive. Aside
from instances to which I have already alluded in other papers,
I quote, e. g., the following : " Cripps has reported the case of a
woman with extensive cancerous ulceration of the left mammary
region, who, being unable to wear any dress, had kept her arm
bent at a right angle and in constant contact with the disease
for several months, in consequence of which the skin in the
vicinity of the elbow became the seat of a cancerous ulcer sev-
eral inches in diameter." A similar instance has been already
reported by De Morgan. Instances of the spread of disease by
contact infection from the uterus to the vagina have been re-
ported by Thorn and many others. Thorn's case was a woman,
aged forty-six years, whose uterus had been deflected to the
right and retained by adhesions. Owing to this bad position,
the cancerous excrescence was constantly in contact with the
left side of the vagina, where another cancer developed which
fitted that on the cervix " like a saucepan lid." Elsewhere the
vagina was free from disease. Numerous cases are on record
where the primary outbreak of the disease in the fundus has
been followed by similar lesions of the cervix. The cases in
which cancer of the upper alimentary tract has been followed
by others lower down are common, and Moxon has described
the spread of the disease along the trachea to the lungs in a
similar way. Cancer in the pelvis is often apparently due to
infection with nodules detached from cancerous growths in the
upper part of the abdomen, while visceral cancer projecting into
the peritoneal cavity often infects the exposed tissue with which
it comes in contact. Numerous cases are now on record of
cancer along the track of the trocar used in tapping for ascites
due to cancerous disease. Surgeons now quite generally admit
this traumatic dissemination of the disease by inoculation of
wounds during operations. Schopf reports cancerous infection
of the lateral incisions into the vagina and vulva necessitated
in the course of vaginal hysterectomy for cancer.
Roger Williams closes his section on this subject by repeating
the warning now so often given that care should be taken to
O PARK,
avoid cutting into the malignant neoplasms during their re-
moval, for " such is the great tenacity of life and the wonderful
proliferative power of even the most diminutive fragments of
cancer that when left behind they only too often constitute
fresh centres of disease." If this is not a virtual admission of
the infectious nature of the disease by one of its strongest
opponents I scarcely know how to regard it.
It will probably not be amiss now if I ask your attention to
some recent work which has been done in the State Laboratory,
conducted under the auspices of the University of Buffalo. We
have enjoyed exceptional facilities in that laboratory for the
study of cancer, it having been founded for the purpose, and
generously maintained and supported by the State. Some
years ago I outlined in a paper which partially treated of this
subject the general lines of investigation which I thought it
would be necessary to follow in order to arrive at more accu-
rate notions regarding the nature of cancer. These included
not only the ordinary histological and bacteriological methods
of investigation, but I also at that time insisted that the subject
should be studied from a biological and from a chemical stand-
point. The latter method had never been undertaken in any
systematic way until we began it in this laboratory, where we
have now a competent biological chemist, and are at last able
to study the disease in some of those relations which have been
hitherto either misunderstood or not understood at all. The
studies already made have seemed to make it clear that death
in cases of cancer comes about, as in so many other diseases,
by a sort of terminal infection, which is a conspicuous feature
of the disease, and has not hitherto attracted sufficient attention.
It appears to us as though the end is finally brought about by
a distinct toxivmia, and particularly by a sort of hrematogenous
infection. This has been made more clear by a study of the
experimental side than by the clinical side of the disease. In
all our animals inoculated and injected this feature has become
so very distinct as to be positively striking. The exact nature
of these terminal changes has not yet been made out beyond
what is implied in the term " hii;matogenous." Moreover, as
ADDRESS OF THE PRESIDENT. J
I have previously indicated in another paper, the cachexia which
is so pronounced a clinical feature of cases of cancer is produced
by varied and varying causes, and it is hard to ascribe to the dis-
tinct toxjemia of this disease its proper role. Much more can
be learned about the disease by experimental research than by
speculation concerning clinical features.
In a paper which I presented to this Association in 1898 I
argued at some length for the infectious or parasitic nature of
this disease. At that time I had just returned from Italy, and
was particularly conversant with the work done by the Italian
investigators, who seemed to be almost unanimous in belief as
to the vegetable — /. e., fungous — nature of these parasites. If in
the succeeding years views regarding their nature have gradu-
ally changed, it may be but a natural outcome of further ac-
quaintance with the bodies in question and a more complete
recognition of their extraordinary polymorphism, as well as our
ignorance regarding the protozoa, especially regarding their
life histories. The predictions of the Italians have failed in
many respects, and it is by no means so easy to successfully
inoculate animals with the yeast as had been generally sup-
posed, but the differences that have come about in our own
views in Buffalo have been essentially the outcome of our
own experimental work. Perhaps I can best illustrate this by
epitomizing some of the work as recently reported by my col-
league. Dr. Gaylord, who really has directed it, and is entitled
to the credit of it.
In August, 1898, I explored the abdomen of a patient, the
case being one in which a clear diagnosis of intra-abdominal
carcinoma could be made, but beyond that no accurate con-
clusions reached, because of the distention by ascitic accumula-
tion. The fluid from the patient's abdomen was collected in
abundance, and it was in this fluid that the bodies which have
since so attracted attention were by us first observed. Ana-
tomically the case eventually proved to be one of adenocarci-
noma, probably arising from the appendix, spreading, involving
the greater portion of the peritoneal surface of the omentum and
mesentery, and then undergoing mucoid degeneration to such
8 PARK,
an extent that when the abdomen was opened at the operation
simply a mass of soft cancerous contents was exposed. The
fluid, which was removed through a sterile tube, and remained
bacteriologically sterile at the end of two weeks, contained a
large number of small hyaline bodies, which, under the micro-
scope, were seen to change in size and form and to pass
through a cycle of development up to what appeared to be a
spore-forming stage. These bodies were first mistaken for fat
droplets, but did not react to ether or osmic acid, as fat usually
does. They were injected into animals. Those which received in-
jection into the peritoneal cavity developed no tumor formation,
but marked peritonitis and enlargement of local lymph nodes.
In their peritoneal fluid the same characteristic spherical nucle-
ated bodies, or sacs filled with granules, were found. When
these bodies were kept a few days in a thermostat they not only
changed their form, but apparently developed into larger struc-
tures, in many of which pseudopodia were seen. In one slide
at least twenty such organisms were arranged around an air-
bubble, all of them with long pseudopodial projections, as
though by some chemotactic excitation. Another animal whose
jugular had been injected was found fifty days after injection
with white nodules in the lungs, which, on microscopical exam-
ination, proved to be minute adenocarcinomata. The tumor
cells, as well as cells from enlarged follicles found in the spleen,
were found to contain adventitious bodies of unusual appear-
ance. Those of the splenic pulp corresponded to Russell's
fuchsin bodies, while in the perivascular spaces Plimmer's
bodies — i. e., half-grown organisms — were found in large num-
bers, just as he has found them in carcinoma in man.
Attempts to cultivate these organisms at the time were not
successful, but success was met with later, the culture medium
giving the best results being that recommended by Celli for the
cultivation of amoeba — z". ^.,a bouillon made with fucus crispus.
Other animals inoculated at this time also developed evidences
of peritonitis, splenic enlargemeut, and pulmonary oedema. In
their peritoneal fluid, as well as blood, and in the organs, large
numbers of these parasites were detected, while sections since
ADDRESS OF THE PRESIDENT. 9
stained by Plimmer's method revealed the presence of numer-
ous parasites in all of the viscera, especially in the lymphatics.
As an outcome of the experiments we were especially directed
toward investigation of fresh scrapings from cancer. Starting
with the assumption that the small spherical bodies which so
closely resembled fat are not fat. Dr. Gaylord endeavored to
determine how the great discrepancy between the large number
of parasites found in fresh cancer and the small number in sections
could be accounted for. Moreover, examination of numerous
tumors shows that in all rapidly growing tumors a great num-
ber of organisms are present. Comparing tumors removed by
operation with those removed post-mortem, it became evident
that the organisms either increase rapidly during the period just
before death or that they proliferate in the tissue immediately
after death. In two cases of large tumors examined immediately
after operation, and found to contain numerous organisms which
yet remained sterile to ordinary methods, the following obser-
vations were made : Repeated examinations of successive scrap-
ings made at intervals of several hours showed that the relative
size of the organisms increased. In the course of ten hours
repeated scrapings showed that amoeboid forms were greatly
increased in number, and that after twenty-four hours the " mo-
rula," or spore-bearing stage, had been reached. At the end of
three days the spore-sacs were completely replaced by groups
of hyaline bodies considerably larger than those which the sacs
originally contained. From this it would appear that the so-
called fatty degeneration of carcinoma cells is at least in some
part due to the presence of organisms which have been mis-
taken for fat droplets or for epithelial cells in advanced fatty
degeneration.
It was also possible to determine that cancer juices (or so-
called cancer milk of some of the older writers) consist almost
entirely of pure cultures of these organisms ; also that fluid from
malignant ovarian cysts contains them in large numbers, as does
also the peculiarly characteristic soft mass found in the cavities
of certain adenocarcinomata of the ovaries. Thus in practically
all scrapings from cancer could be seen either small hyaline
lO PARK,
refractive forms, which in suspension possess a characteristic
oscillating motion, or larger forms with projecting pseudopo-
dia, or saccular forms containing very refractive spherical bodies.
By incubating hanging-drop preparations of fresh scrapings
from cancer the smaller forms can be followed in their de-
velopment as they increase in size, and if kept upon a warm
stage they may be seen to throw out especially developed
nuclei, and conclude their life history by a formation of a sac
in which they develop their spores. Since the specific gravity
of these organisms is less than that of water they rise to the
surface in the hanging-drop, and are to be sought directly be-
neath the cover-slip, and not in the lower portion of the fluid.
Having learned the nature of these changes in the hanging-
drop outside the body, it became necessary next to determine
why they could not be more easily demonstrated in the tissues
by ordinary staining methods. It was then found that nearly
all the fixatives in common use cause the disappearance of all
the spore-sacs and the greater part of the more developed or-
ganisms. Only two small, more resistant forms remained, and
these would take the ordinary aniline stains. These now appear
to be those forms seen so long ago by Russell and so generally
known by his name. A little later in their life-history these
reach such a stage of development and size that it is often im-
possible to state whether they are parasites or tissue elements.
In one case, however, of carcinoma of the bladder, where these
organisms appeared in large numbers in the urine, Gaylord was
able to detect these forms between epithelial cells and attached
to the surface of the tumor after its removal.
Another experience encountered in the summer of 1898 made
a profound impression upon our minds. An autopsy was made
upon a patient who had died of carcinoma of the uterus. It
disclosed advanced general peritonitis with abundance of fluid,
such as would ordinarily be produced by perforation and ex-
tension. It was found, however, that there was absolutely no
perforation, and the peritonitis seemed to be due to a general
infection whose source was to be traced. Further preparation
was made by Gaylord from the surface of the peritoneum, the
ADDRESS OF THE PRESIDENT. II
spleen, the lungs, and the blood, showing large masses of pale
hyaline forms seen so often in fresh scrapings, in the peritoneal
fluid of cancer, and in the blood and fluids of experimental
animals.
In January, 1899, before the Medical Society of the State of
New York, Dr. Gaylord and myself both stated that we be-
lieved he had recognized and demonstrated the presence of
parasites in cancer and had successfully reproduced cancer in
animals, but that we were at that time not in a position to
state positively the nature of these parasites. Since that time
most elaborate studies have been made, both of experimental
animals and by post-mortem examination of patients dying of
cancer, and Dr. Gaylord is now able to demonstrate that all the
organs of cases dying of cancer, including sarcoma and epithe-
lioma, also the blood, contain large numbers of the Organisms.
What shall be said with regard to the yeasts and the fungi
which numerous observers, especially among the Italians, be-
lieve to be the actual parasites of cancer ? It certainly is true
that Sanfelice has produced neoplasms, essentially tumors, in
animals, by inoculation with the yeasts which he cultivated;
but this occurred only in isolated instances, and can be regarded
as proving only that the yeasts are pathogenic, but not certain
cancer producers. That fact had already been made plain by
Busse, independently of the Italian observers. The yeasts cer-
tainly have their pathogenic role, and are now known to pro-
duce certain skin lesions as well as to be associated with
certain internal diseases, and occasionally with the forma-
tion of pus. Nothing has yet been established to prove that
they may not in occasional instances produce cancer, but so
far at least as our Buffalo researches are concerned we have
to report that the Italian observations have been neither abso-
lutely disproven nor confirmed. Sanfelice was unable to culti-
vate the organisms from the region of inoculation, but was in
many instances able to regain them from the regional lymph
nodes. By transferring these from animal to animal he en-
hanced their virulence to such an extent that they became fatal
to the animals in which they were injected.
12 PARK,
Further difficulty is added to this line of investigation by the
extraordinary polymorphism of many of these minute organ-
isms. Even the yeasts and fungi undergo numerous changes in
size, and doubtless this is true to greater extent of the protozoa.
Plimmer, of London, has rendered most signal service in this
direction by his extraordinary patience and the number of his
investigations. During a period of six years he examined micro-
scopically 1278 carcinomata. In 11 30 of these cases he found
those parasitic bodies which are now associated with his name.
They were found in all portions of the cancer, but especially at
the growing edges. They appear only in the active cells and
not in those which are undergoing degeneration. They appear
also between the cells, and even in the leucocytes. In the more
rapidly growing tumors they are found in large number. He
has found even as many as sixty in one cell. Comparing sec-
tions of cancer with those of other growths, granulomata, etc.,
as well as normal tissues, he stated positively that he had never
seen in any instance, save in cancer, bodies which resemble
these parasitic forms or which have their reactions. The claims
made by Plimmer have been almost faithfully corroborated by
work done in the Buffalo Laboratory, and substantiate his claim
that these bodies are present in practically all carcinomata.
They may be demonstrated in the fresh state, although here it
is somewhat difficult to differentiate them from the fat droplets
which they resemble. The most minute forms might be con-
fused with cocci. The maturer forms appear either as spherical
bodies with delicate outlines, or in full form, as well within as
without the cells. Sometimes pseudopodia may be seen, in
which case their contained granules remain for the most part
in the larger portions of the structure. Sometimes the extra-
cellular bodies may be observed to change their form by
placing them in a thermostat. Summing up these investigations
of Plimmer's bodies, it may be stated that they present character-
istic appearances, and can be differentiated from cell-degenera-
tions of the usual type as well as from other structures which
they may resemble. It has never been possible to make out
degenerative changes in the epithelial or other cells in cases of
ADDRESS OF THE PRESIDENT. I3
cancer which can really be confused with the so-called Plim-
mer's bodies.
It is extremely probable that most, if not all, of the observers
who have described and figured cell inclusions have been watch-
ing the typical Plimmer's bodies. This is particularly true of
Sjobring.
Culture experiments made in our laboratory by the ordinary
bacteriological methods have been uniformly negative in result.
In order to show that they have been assiduously tried, I would
say that sixty-four different media, including about everything
that has ever been suggested and some original formulfe have
been employed, and of various degrees of acidity and alkalinity.
Per co7itra, the organisms have been usually obtained by culti-
vation after experimental inoculation in animals. In those
instances in which yeasts were employed, it has been possible
to produce a pretty typical blastomycetic mycosis with abscess
formation or characteristic infectious granuloma.
Matters rested in this state in our laboratory for two years,
our staff, and especially Dr. Gaylord, varying in opinion as the
evidence seemed to present itself one way or the other, inclin-
ing at times to the view that parasites were fungi and at other
times that they were protozoa, the difficulties of the research
being such that it seemed most difficult to weigh the evidence
and reach a satisfactory conclusion. This was, however, at last
and recently hastened by the investigations of Copeman and
Funk on the protozoa of vaccine lymph. Section of rabbit
cornea which had been inoculated with vaccine virus showed
not only that the half-grown formation of the vaccine organ-
ism is closely related in appearance to Plimmer's and Russell's
bodies, but that the life-cycle of this organism seemed to epit-
omize that of the cancer parasites which we had been studying.
Going over the old work which had been done by methods
previously in use, in the light of these latest researches on vac-
cine organisms, very positive conclusions can now be reached.
It would appear, for instance, that the protozoa are capable
of producing in man (as Pfeiffer showed that they might pro-
duce both in man and in animals) lesions of widely different
14 PARK,
nature from mere infection of epithelium. For instance, in a
pustule found upon the surface of a cancerous breast which I
removed in February of this year, Dr. Gaylord found a quantity
of material, consisting of leucocytes, red corpuscles, and a very
large number of cells which proved to be protozoa. On cutting
into the breast and making fresh scrapings, these were found
to consist of closely packed epithelial cells, fat droplets, and a
considerable number of small greenish hyaline bodies of high
refractive index, and corresponding in every way to the Plim-
mer's bodies and to the parasites already described. Sections
stained in the ordinary way, as well as by Plimmer's method,
show also the same condition. Sections of the region of the
pustule above mentioned show a tremendous number of spher-
ical and oval Russell bodies as well as large cells with more
than one nuclei, many of them containing spherical bodies like
Russell's. This pustule would appear to have been the result
of an embolic deposit of parasites from the cancer itself, and we
naturally interpreted it as indicating that the organisms of can-
cer are capable of producing other lesions than mere epithelial
infection.
In a short time full report will be made of the results of
inoculation of seventy-two animals. The material with which
they were inoculated consisted of peritoneal fluid, fluid from
the interior of malignant ovarian cysts, bacteriologically sterile
cancer and dried cancerous lymph nodes rubbed up with salt
solution. Some of the latter contained metastatic cancerous
deposits, while in a number Russell's bodies were detected.
In each case the fresh material was carefully examined and the
presence of parasites determined before inoculation.
Briefly epitomizing the results obtained, we have the following
interesting features : Fourteen guinea-pigs inoculated in the peri-
toneum with peritoneal fluid containing the organism had an
average life of fifty-eight days ; four inoculated in the peritoneum
with cancer mush, an average length of fifty-eight days; eleven
inoculated in the peritoneum with dry cancerous lymph nodes,
forty-five days ; while six guinea-pigs inoculated with material
from these animals already infected gave an average length of
ADDRESS OF THE PRESIDENT. I5
life of twenty-nine days — but little more than half the length
of time for the animals inoculated directly from man. Only
one interpretation can be put upon this, and that is the increased
virulence obtained by passing the organism through even one
animal. By other experiments, organisms grown in a collodion
sac within the peritoneal cavity of rabbits were so enhanced in
virulence that a healthy rabbit inoculated in the ear vein died
within fifteen days of general haematogenous infection. Thus
it will be seen that animals are rapidly infected when inoculated
with cancerous material proven to be bacteriologically sterile,
and consisting essentially of pure culture of the cancer parasites.
All these animals rapidly emaciated, and presented, on opening
the abdominal cavity, enlarged peritoneal lymph nodes, an in-
crease in fluid, and enlargement of the spleen. Several of the
animals presented also minute nodules in the lungs, which we
are quite justified in interpreting as beginning adenocarci-
noma, while similar nodules were noticed in other instances in
the liver and spleen. In all of the organs thus far examined by
Plimmer's method large numbers of parasites were found in
various stages of development. The lungs in all instances show
that the parasites have penetrated the bronchial epithelium, caus-
ing a typical proliferation and epithelial nests beneath the base-
ment membrane, practically such lesions as Pfeiffer described ten
years or more ago in many of the lower forms of animal life.
The mention of protozoa as active agents in the production
of cancer will strike no one as a novelty. The lowest forms of
animal unicellular life have been regarded, as it were, as disease-
producing agents for a number of years. Among the most
conspicuous investigators of this subject has been L. Pfeififer, of
Weimar, who has published monographs at various times on
this special subject. Published as they were, they seem to have
attracted less attention than they deserve or would if they had
been printed in some journals of wide circulation. So early as
1890 Pfeififer had written and studied most extensively on this
subject, and his investigations are remarkable examples of the
fidelity and patience with which some of the Continental inves-
tigators pursue such studies.
l6 PARK,
Then we have had recent descriptions of Eisen's cancriamoeba,
showing that so far as the microscope alone could take him he
was working in the right direction. There is also, for instance,
Korotnefif's^ rhopalocephalus carcinomatosus, which he has
figured and described with infinite pains. There are, further,
Bosc's description and plates of myxosporidia, coccidia, etc.,
which present very similar appearances. But the most elabor-
ate monographs of all dealing with this side of the subject are
those of Pfeiffer." He attacks the matter from the comparative
stand-point, which is by far the most successful one, and shows,
for instance, how epithelial proliferation is provoked in the lower
forms of life and by many parasitic forms belonging to the pro-
tozoa. Thus clepsidriana will produce in the intestine of the
golden beetle (chrysomela) and the horned beetle (carabus) epi-
thelial proliferation by which a heaping up of cells and almost
miniature tumor formation are produced. This is particularly
true in the case of the intestinal lesions produced in the beetle
by actinocephalus. Tumor formation in the spermatoblastic cells
of the earthworm is produced by certain of the momocystidia,
while klossia produces a similar effect in the kidney tissue of
certain snails. Coccidiosis is now well known, especially in the
rabbit and the domestic mouse, as the explanation of certain
neoplastic lesions. Infection by certain sporidia produces gen-
eral muscle tumors in the hog, sheep, horse, and other animals.
The name myositis gregarinosa is given to certain muscle-
tumors caused in the horse by sarcosporidia, and to tumors in
the oesophagus and pleura of sheep produced by similar organ-
isms. Pfeiffer found also muscle-tumors produced in pickerel
and other fish by myxosporidia, as well as tumors of various
viscera, and even the heart substance. These parasites also
produce neoplasms in nerve-trunks, thus leading to lesions
which he describes as polyneuritis parasitica. They also pro-
duce tumors in the swimming bladders of the horse-mackerel
' Sporozoen als Krankheitserreger.
- Die Zell-Erkrankung und die Geschwulstbildung durch Sporozoen, and Die Protozoen
als Krankheitserreger.
ADDRESS OF THE PRESIDENT. 1/
(caranx), which he considers expressions of endothelial infec-
tious tumors.
A close study of these comparative lesions and of tumor
formations in human beings leads Pfeiffer' to say: "When the
cancer parasite is an obligate cell, parasite cultivation, accord-
ing to the ordinary bacteriological methods, cannot succeed, or,
if at all, probably only in the hen's egg as a medium."
Having thus called your attention to some of his researches
upon the role which the protozoa play in comparative pathol-
ogy, let me remind you of what he has done and found con-
cerning their activity as disease-producing agents among human
beings. The dermatologists meet frequently with a disease
which we call molluscum contagiosum. A similar lesion is
met with also in birds, and especially among domestic fowls,
pigeons, etc., and is seen upon the head, neck, eyelids, inner
surface of the thighs, and about the anus. In birds it seems
often to be accompanied with a formation of false membrane
upon mucous surfaces, giving rise to the term avian diphtheria.
This, however, is a most unfortunate expression, since it has
nothing whatever to do with our diphtheria. In human beings
similar tumors appear on all parts of the human body and seem
to possess a certain degree of contagiousness or infectiousness.
Thirty years ago Virchow called attention to the resemblance
between the so-called molluscum bodies and certain protozoa
found in the intestine and liver of rabbits. In 1873, Bollinger
called attention also to the resemblances between these new
formations and what was known as bird-pox. He it was who
first gave it the name of epithelioma contagiosum. In 1890,
Pfeiffer fully described the peculiar infection of the epithelial cells
by protozoa, and figured characteristic appearances in his book.
He also showed, as have Barrier and Wickham, the protozoan
nature of Paget's disease of the nipple, agreeing with these
other authors as to the nature of the disease, and illustrating
the gradual invasion of the milk-ducts by these parasites.
Pfeififer also called attention to the changes occurring in
• Die Zell-Erkrankung und die Geschwulstbildung durch Sporozoen, and Die Proto-
zoan als Krankheitserreger, p. 97.
Am Surg 2
l8 PARK,
epithelial cells in herpes zoster and the eruptive diseases of
children. He showed how, in a fresh herpetic vesicle, the
epithelium could be found packed with protozoa, and how the
latter could also be seen in the fluid and in the tissues. Similar
vesicles produced by burning, by croton oil, etc., did not show
these evidences of parasitic infection. This is of practical in-
terest in connection with some of the herpetic eruptions seen
along with cases of cancer. In a later monograph published in
1895, Pfeiffer claimed to be among the first who had determined
the animal nature of certain parasites seen in tumors, and espe-
cially in carcinoma and sarcoma. He did not claim to have
succeeded with inoculation experiments, but was sure of the
microscopical appearances. In this publication he gave numer-
ous illustrations of the parasites in the epithelial cells, which,
save for a certain coarseness of drawing, would pass muster
to-day. He shows, for instance, the parasitic infection of
muscle cells, and even their nuclei, with zooglcea spores, and it is
impossible to examine his brochure without feeling that he was
far ahead of his generation in his recognition of the important
role played by these animal parasites.
Pfeiffer also set the first example in a careful study of endemic
cancer and of localities in which it occurs. He presents a small
map of the village of Grossobringen in the neighborhood of
Weimar. The little village contains about six hundred inhabi-
tants. During the previous twelve years nearly three times as
many had died of cancer as of tuberculosis. He showed that
in this small town the mortality rate from cancer was much
higher than of the adjoining country or villages. While it can-
not be said that he presented a reasonable explanation therefor^
this report of Pfeiffer's must still stand as an illustration of topo^
graphical study of the most important kind, antedating Behla's
similar investigation of the town of Liickau, to which reference
has often been made. But I must pass on, lest other matters
of importance in this connection be neglected.
Certain observances have been made regarding these parasitic
forms which may be stated somewhat succinctly as follows :
These organisms can be found in regional lymph nodes before
ADDKESS OF THE PRESIDENT. I9
epithelial deposits are detected in the same. This would seem
to imply that they travel ahead of the epithelial cells, and would
seem also to take away the force of that argument which was
perhaps put forward first by Rindfleisch, who spoke of the in-
fectivity of epithelial cells. The parasites, thus being much
smaller, may much more easily enter the lymph stream when
liberated.
The constant occurrence of young forms of parasites around
the periphery of a growing tumor, where they more easily get
into both blood and lymph streams, is also of significance, taken
with the above. Just how early they make this entrance into
the current is a matter yet to be determined, as also whether
there is any clinical or pathological sign by which such event
may be indicated.
In all cancer cadavers so far examined we have found organ-
isms in all the organs, and even in the peripheral blood, in
every instance, showing how widely the organisms are thus
diffused and the far-reaching effect of a primarily local infec-
tion. Also all patients so far examined in whom cachexia has
been extreme have given the same result so far as the periph-
eral blood was concerned. They seem always to be found in
this fluid.
Malignant lymphoma is a disease about which in times past
no small differences of opinion have existed. This would appear
from the variety of names which have been given to it, if on no
other account. It certainly presents a great variation in degree
of malignancy, some cases being exceedingly rapid and acute,
and some slow. In two cases of mine of more rapidly growing
type, one of which was fatal without operation, the other under-
going it and recovering, parasites were found in the circulating
blood — in the former instance seven days before death. Such
cases as these would seem to be instances of primary lymph or
recurring infection. The more rapid in type the greater the
danger and degree of haematogenous infection. The slower
forms of this kind are commonly those usually known as
Hodgkin's disease, appearing in its slow type, or at least are
barely distinguishable from it. The microscopical changes in the
20 PARK,
lymph nodes, disregarding changes in the blood, which are seen
in malignant lymphoma. Hodgkin's disease, and leukaemia, are
barely distinguishable from each other, if at all. So, too, the
changes in the spleen in chronic leukaemia, chronic malaria,
and splenomegaly (Banti's disease), barring, of course, increase
of leucocytes in the former and the presence of malarial para-
sites in malaria, are barely distinguishable from each other.
We seem to have two quite different types of lymph infection
— those in which the lymph-nodes especially are involved, as
in malignant lymphoma and Hodgkin's disease, and those in
which the spleen especially is involved, as in the disease last
mentioned. The position of malaria at one end of this list and
of malignant lymphoma at the other, protozoa being respon-
sible for each of them, would seem to imply that all the inter-
mediate conditions must necessarily be regarded as protozoan
infections, aside from the actual microscopical findings. In this
respect the recent work of Lovvit, which is exceedingly sug-
gestive, must not be overlooked.
Those diseases in which enlargement of the spleen forms a
prominent feature have been in times past attacked surgically
until the number of failures in attempting to relieve lymphatic
spleens has led almost to the abandonment of splenectomy for
this purpose. The primitive form of splenomegaly (Banti's dis-
ease) has given much better results after operation than any of
the other morbid conditions of the spleen, and this may now be
explained, since in this condition the infection is still local, in
whole or in part, and more resembles malignant lymphoma. If
leukremia is a protozan disease, as Lowit claims, it is on a par
with malaria, and must be regarded as a specific infection of the
leucocytes like malaria, in which case splenectomy would be
very much less promising. It is only when the lymph nodes
or spleen are primarily infected and most conspicuously in-
volved that the case becomes essentially a surgical one.
Cancer begins as a purely local infection. This is a statement
which I have repeated for many years, and which would seem
to be verified by our recent work in Buffalo. It kills by becom-
ing generalized. This is also true of tuberculosis, and while
ADDRESS OF THE PRESIDENT. 21
there are possible exceptions in each case, the general state-
ment thus made can scarcely be denied. Miliary carcinoma-
tosis is not much more rare than miliary tuberculosis, and these
constitute apparent exceptions to the above rule. Even they,
however, do not prove that the disease does not have a local
beginning. In each case operation, if done before general in-
fection has occurred, or metastasis has taken place, is exceed-
ingly promising, if done thoroughly. This statement, of course,
is backed up by universal experience, but finds its explanation
in what I have already said. Operations done later are pallia-
tive in that thereby a large focus, or depot, or principal source
of supply is removed, its removal not only lessening danger of
general dissemination, but permitting the blood to assert its
own normal parasiticidal properties.
More specific illustration of this statement may be found in
cancer of the stomach, where a successful gastro-enterostomy
saves the patient from death by starvation, but does not avert
his final cachexia and terminal h?ematogenous infection. It
prolongs his life only indirectly and for but a short time. On
the other hand, radical operation when successfully done seems
to really prolong life and to remove cachexia, as theoretically
should be the case when the principal source of infection is
extirpated.
Take the case, again, of a successful splenectomy for primary
splenomegaly. It at all events produces great temporary benefit,
and often leads to a practical cure. It has hitherto been sup-
posed that the splenic enlargement was due to absorption of
toxic substances from the intestines. If this were really the
explanation splenectomy would be ridiculous. On the other
hand, if the primary infection be in the spleen and the source
of supply limited to that organ, then its removal would be most
strongly indicated and should prove of the greatest benefit. It
remains yet to be positively demonstrated that Banti's disease
is really a protozoan infection, since I doubt if yet any inocula-
tions of such splenic pulp have ever been made into animals. It
is, however, a promising field for research.
If these statements have aught of actual value, this value is
22 PARK,
extreme, since they should teach that in dealing with primary
lymphatic infections of such structures as the spleen and lymph
nodes extirpation done early is of the greatest importance and
should not be neglected. It is most indicative also, in my esti-
mation, that in our laboratory experiences Gaylord succeeded just
as well when inoculating animals by using old dry lymph nodes
as by introducing fresh elements. This suggestion is, so far as
I know, original with him, and seems to have a far-reaching
importance, that organisms may remain in the dry tissues for
considerable lengths of time and still prove effective when in-
oculated. This is, however, just what we see with vaccine
lymph, for instance, while the resemblances between the pro-
tozoa of such lymph and those of cancer have already been
strongly touched upon.
I want to make it as evident as possible that carcinoma as a
type of disease is in every instance an example of epithelial in-
fection. Sarcoma, on the other hand, is an infection of con-
nective tissue, probably by the same organisms, the tissue cells
reacting somewhat differently. It would seem, so far as we
have ^one, that different forms of parasites have specific ten-
dencies in one direction or the other; but it will take years of
minute and careful study to show which kind of parasite pre-
fers one or the other of these tissue cells. Up to a time within
a (ew years ago, and quite easily within our recollection, ma-
laria was almost as much a mystery as has been cancer. Now,
we recognize at least three distinct types of malarial parasite,
and talk and think of these organisms as if we were reasonably
acquainted with them. We have, then, ample grounds, reason-
ing by analogy, for supposing that cancer organisms may in
some manner manifest specific inclinations. Moreover, those
animals which were inoculated with sarcoma showed predom-
inant sarcomatous lesions, although epithelial infection was not
entirely wanting. For instance, in the first animal inoculated
from my first case, which was so carefully worked up, although
the predominant lesion was adenocarcinoma of the lung, it was
nevertheless found that all of the splenic follicles (which are of
connective tissue origin) were likewise infected.
ADDRESS OF THE PRESIDENT. 23
Authentic instances of mixed sarcoma and carcinoma are, in
man, clinically rare, but we may note, for instance, in Cullen's
recent work the frequency with which myoma and uterine can-
cer are associated, and this is made still more apparent by
Wadsworth's recent paper illustrating the frequent occurrence of
these lesions.
An entirely different aspect of this question is still left un-
touched by our researches, and one to which in time past I have
invited your attention, and that is the possibility of spontaneous
retrocession or disappearance of malignant growths. I had
thought to get together for presentation to you at this time the
views and reports of various surgeons, in all parts of the world,
upon this topic, but was prevented doing this by press of other
work. I have for years maintained that in rare instances ma-
lignant tumors have undergone a spontaneous and mysterious
retrocession for which it was impossible to account in any
known way. While some surgeons have denied that this is pos-
sible, others have maintained, as I do, that it has occurred under
their personal observation. Most recently, in this connection,
similar instances have been reported by one of our medical
confreres. Osier/ whom we surgeons always delight to honor.
There is nothing in the protozoan theory of cancer which makes
this appear less possible or plausible than before, nor is there
anything which shows it to be impossible. We see startling
recovery from other infections in cases where hope had been
abandoned, and there is no reason to think that such a thing
is impossible, even in dealing with so dreadful a condition as
cancer.
' American Medicine, April 13, 1901, vol. i. p. 65.
THE EARLY SIGNS OF CARCINOMA OF THE
UTERUS.
By THOMAS S. CULLEN, M.D.,
BALTIMORE.
Dr. Cullen gave a lantern exhibition illustrating the early-
points in the diagnosis of cancer of the uterus. In commencing,
he briefly outlined the normal histology of the uterus, showing
sections of the squamous epithelium of the vaginal portion, the
racemose glands of the cervix, with their characteristic high
cylindrical and pale-staining epithelium, and the tubular glands
of the body. He pointed out that from each of these varieties
of epithelium a different form of carcinoma may develop.
Squamoiis-celled Carcinoma of the Cervix. The suspicious
changes in the epithelium near the edge of the growth were
shown. Then the gradual transition of normal into carcino-
matous epithelium portrayed, and finally the involvement of the
underlying stroma. Great stress was laid on the increase in
size of the cell, associated with the formation of large, irregular,
and deeply-staining nuclei.
Adenocarcinoma of the Cervix. Several examples of early
gland alteration were given and of carcinoma developing from
the surface epithelium. Gross specimens were also shown
where the organ was normal in size and contour, and where,
without the timely aid of the microscope, a positive diagnosis
would have been impossible.
Adenocarcinoma of the Body of the Uterus. The doctor pointed
out that the microscope is of the greatest value in the diagnosis
of carcinoma of the body and at a time where the symptoms
or the bimanual examination reveal little. He demonstrated
SARCOMA OF THE UTERUS. 2$
slides showing a commencing tit-like outgrowth from the sur-
face of the mucosa, and traced this until the typical carcinoma
had developed; the commencement of the carcinoma in the
glands was also depicted. Much stress was laid on the gland
grouping and upon the size and staining reaction of the cells.
The doctor said that the diagnosis can be made in nearly every
instance, even if no muscular tissue be present. Many cases
were cited, the scrapings being shown, and then the diagnosis
clinched by the gross specimen after removal.
The doctor briefly mentioned certain changes that might be
mistaken for commencing carcinoma of the body. Among
these were alterations due to imperfect hardening, to gland
hypertrophy, and occasionally to endometritis. In conclusion,
he pointed out the necessity of having a thorough knowledge
of the normal mucosa before attempting a. study of the patho-
logical changes.
BRIEF CONSIDERATION OF CASES OF CANCER
OF THE BREAST TREATED AT THE JOHNS
HOPKINS HOSPITAL SINCE 1889.
BY W. S. HALSTED, M.D.,
BALTIMORE.
Dr. Halsted explained that in the Johns Hopkins Hospital
drawings are made of all cases of cancer, and paintings are
made of some. Some 320 cases of cancer of the breast have
been operated upon in the above-named hospital since 1889,
and about 150 of these during the past three years. There
have been 450 cases of tumor of the breast since 1889; of these
only 3 were sarcoma, and but i of these was primary. Adeno-
carcinoma is not very malignant, but always becomes malignant.
Dr. Halsted explained the difficulty of compiling trustworthy
statistics. Many hopeless cases were operated upon simply for
temporary relief, and these should not be counted in with more
hopeful cases. He had divided his cases into three groups :
(l) Those from which the axillary and supraclavicular glands
were removed at the primary operation ; (2) those from which
the supraclavicular glands were not removed until a secondary
operation ; (3) those from which the supraclavicular glands were
not removed at all. Local recurrence occurred in group (i) in
II per cent., in group (2) in 20 per cent., and in group (3) in 9
per cent, of cases. In group (i) 45 per cent., in group (2) 33
per cent., and in group (3) 43 per cent, were cured. Intra-
canalicular myxomas and fibromas are often spoken of as
sarcoma, but they are not such.
LATE RESULTS OF THE TREATMENT OF INOPER-
ABLE SARCOMA WITH THE MIXED TOXINS
OF ERYSIPELAS AND BACH.LUS
PRODIGIOSUS.
By WILLIAM B. COLEY, M.D.,
NEW YORK CITY.
In May, 1894, 1 was highly honored by an invitation from the
American Surgical Association to read my first paper upon the
treatment of inoperable malignant growths with the mixed
toxins of erysipelas and bacillus prodigiosus. The results up
to that time, though remarkable, covered a comparatively small
number of cases and had not stood the test of time. Yet the
words of kindly encouragement then received from the mem-
bers of the American Surgical Association did much to stimu-
late my enthusiasm and helped me to persevere during the
period of doubt and discouragement that necessarily attend
the introduction of any new method of treatment of malignant
tumors, and especially the treatment of malignant tumors already
pronounced inoperable and hopeless by competent authorities.
Seven years have passed since the reading of the paper
referred to, and just a decade since the beginning of the ex-
periments of Dr. Bull and myself with the living cultures of
erysipelas in inoperable malignant tumors ; and the question
may well be asked by the profession, " Has the toxin method
fulfilled any of the early hopes and claims ? In other words,
just what, in brief, is its proper place in the therapeutics of
malignant tumors ?"
This question is certainly a fair one, and I shall attempt to
answer it in the briefest possible way and do it after the man-
ner of the judge rather than the advocate.
28 COLEY,
The results of this method during the last three years have
given me no reason to change the conclusions expressed in my
earlier papers, and I have nothing new to add in the way of
improvement in technique or of preparing the toxins. While
the results are far better in spindle-celled sarcoma than in any
other form, there have been a sufficient number of round-celled
sarcomas successfully treated to make it advisable to give every
patient with inoperable sarcoma the benefit of a brief trial. If
no improvement has occurred at the end of three to four weeks
of daily injections, the treatment is not likely to be successful.
If improvement does occur, the treatment should be kept up,
either until the tumor has entirely disappeared or until it has
become evident that the injections have lost their inhibitory in-
fluence. The toxins may be given for long periods in moderate
doses without harm to the patient. The risks of the treatment
are practically nil if proper precautions are observed. In up-
ward of two hundred cases I have had but two deaths, both of
which occurred more than five years ago. It should be remem-
bered that the method is advised only in inoperable sarcoma;
in other words, in the entirely hopeless cases. The percentage
of probable cures depends largely upon the type of cell, varying
from perhaps 3 or 4 per cent, in the round celled to nearly 50
in the spindle-celled variety. Up to the present time I have
had no success with the toxins in the treatment of melanotic
sarcoma, although I have tried the method in about a dozen
cases. In some of these cases the disease was held in check
for some time, but after a longer or shorter period the inhibi-
tory action of the toxins was in some way lost. Lympho-
sarcomas of the neck form another class that, up to the present
time, justifies a prognosis almost as bad as that in melanotic
growths. Although I have treated a large number of such cases
most carefully and persistently, I have not as yet had a single
permanent success. These cases are nearly all of very rapid
growth and very highly malignant. It should be borne in
mind that these lymphosarcomas of the neck are also prac-
tically hopeless from the start from an operative point of view.
Butlin states that he has been unable to find a record of a
TREATMENT OF INOPERABLE SARCOMA. 29
single case in which a cure has resulted from operation. In spite
of these discouraging results in melanotic sarcomas and lympho-
sarcomas of the neck, the remarkable inhibitory action of the
toxins that I have observed in certain tumors of these varieties
justifies us in advising a thorough trial of the treatment in all
such cases, unless the disease is very far advanced or has already
become generalized. After generalization has occurred — what-
ever be the variety of sarcoma — I doubt that any permanent
result can ever be obtained by the toxins.
In August, 1898/ I published my results in 140 cases of
inoperable sarcoma treated with the mixed toxins. In 24 of
these the tumor completely or partly disappeared. Eighty-
four of this series were round-celled sarcomas; 21 spindle-
celled; 9 melanotic; 2 chondrosarcoma; 12 were sarcomas
(diagnosis confirmed by the microscope, but type of cell not
stated) ; 6 were inoperable sarcomas, clinical diagnosis only,
combined with a history of repeated recurrence in most cases.
In 40, or slightly less than half of the round-celled cases,
there was more or less improvement, as shown by decrease in
size and cessation of growth. In only three of these was the
treatment successful.
Of the 21 cases of spindle-celled sarcoma, 10 disappeared
entirely, and all the remainder showed marked improvement.
In melanotic sarcoma, as I have stated, I have had no suc-
cesses. It should be noted, however, that Dr. George R.
Fowler, of Brooklyn, has reported one case of melanotic sar-
coma of the tonsil and fauces, which entirely disappeared under
the use of the mixed toxins. The patient remained well for two
years, when a local recurrence followed and proved fatal.
In addition to these personal results the paper contained a
summary of results in 35 cases successfully treated by other
surgeons employing the same method. Of these 35 cases, 10
were round-celled; 10 spindle-celled; in 5 the diagnosis was
clinical only; in 5 there was, in addition to the clinical signs
of sarcoma, a history of recurrence after operation ; in 4 the
' Journal of the American Medical Association.
30 COLEY,
diagnosis of sarcoma was confirmed by microscopical examina-
tion, but the type was not stated ; i was an endothelio-sarcoma.
Of these 35 cases, 26 disappeared completely; 2 others
decreased so much that only a small node was left, which was
easily excised. One of the latter cases was well three years
and the other one year at the time of the report.
Of the 35 cases referred to, 14 were well over two years and
6 cases over three years.
At the time of my report (August, 1898) 8 of my cases had
remained well from three to six years. I have made a very
great effort to trace the after-histories of these patients, with
the following results :
Case I. — Recurrent, inoperable spindle-celled sarcoma of the neck
and tonsil, treated with the injections of the living cultures of ery-
sipelas in May, 1891, for four months, during which time a severe
attack of erysipelas occurred. The tumors nearly disappeared and
the patient recovered perfect general health. He remained well for
eight years, at which time the malignancy reappeared and proved fatal
during the following year.
Case II. — Recurrent mixed-celled sarcoma (round, oval, and
spindle) of the back and groin. The patient was first treated in
April, 1892, with the living bouillon cultures of the streptococcus of
erysipelas. The tumor entirely disappeared. It recurred two months
later, and finally disappeared under the mixed toxins. During the treat-
ment the patient had four attacks of erysipelas, artificially produced.
He remained well for three and one-fourth years; then had an intra-
abdominal recurrence, of which he died in about six months.
Case III. — Inoperable spindle-celled sarcoma of the abdominal wall
and pelvis, 7x5 inches in diameter. The patient, a boy, fifteen years
of age, was treated at the New York Cancer Hospital in January, 1893.
The tumor entirely disappeared under four months' treatment with the
mixed filtered toxins. The boy was in perfect health when last seen,
between seven and eight years after treatment. The diagnosis was
confirmed by Dr. H. T. Brooks, pathologist at the Post-Graduate
Hospital.
Case IV. — Large, inoperable sarcoma of the abdominal wall. The
patient (female, aged twenty-eight years, had an exploratory laparotomy
performed in August, 1893, at the Massachusetts General Hospital,
TREATMENT OF INOPERABLE SARCOMA. 3I
by Dr. Maurice H. Richardson. Such a large portion of the abdom-
inal wall was found involved that removal was considered impossible.
A portion of the growth was excised for microscopical examination,
and pronounced spindle-celled sarcoma by Dr. W. F. Whitney, path-
ologist of the hospital. The treatment with the mixed toxins was
begun in October, 1893, and continued for about four months, with
the result that the tumor entirely disappeared. The patient remains
in perfect health at the present time, nearly eight years after treatment.
Case V. — Spindle-celled sarcoma of the leg and popliteal space,
three times recurrent. The tumor disappeared under the toxins, but
recurred one and one-half years later. Amputation below the tro-
chanter was performed, but a growth soon appeared in the gluteal
region. This grew in size very rapidly, and was quite inoperable.
The toxins were administered for a number of weeks ; the growth
became more clearly outlined and movable, and the greater portion
of it was removed under ether. The toxins were continued after the
operation, with intervals of rest, for nearly a year. The remaining
portion of the tumor disappeared, and the patient is at present — more
than four years afterward — in perfect health, without any sign of
return.
Case VI. — Spindle-celled sarcoma of the scapular region, involving
the soft parts of the left half of the thoracic wall. The patient, a girl,
aged sixteen years, was admitted to the New York Cancer Hospital
June 20, 1894. The tumor had started in the left scapular region
four months before, and had grown very rapidly, until it measured 13
inches vertically behind, 7 inches in front. The growth seemed ad-
herent to the scapula and the ribs ; it was about two inches in thick-
ness in its most protuberant part. A portion from this region was
removed, under cocaine, for microscopical examination, and the
diagnosis of spindle-celled sarcoma was made by Dr. H. T. Brooks,
pathologist of the Post-Graduate Hospital. The tumor entirely dis-
appeared by absorption, without breaking down, under about three
months' treatment. The after-history of this patient is of great interest,
and will very shortly be published in detail by Dr. Buxton and myself.
She remained well for six years, and then developed a peculiar growth
in the region of the right scapula and right pectoral muscles. A por-
tion of the tumor removed from the pectoral region in October, 1900,
seemed microscopically to be dense fibrous tissue infiltrating the pec-
toral muscle. The diagnosis of progressive muscular fibrosis was
made by Dr. Buxton. Shortly afterward a piece of new bone about
32 COLEY,
two inches long and one half inch in diameter was removed from the
pectoral muscle. A little later a new bony formation occurred in the
region of the sternomastoid muscle, and was removed under ether.
A portion of soft tissue was also removed from the scapular region,
and microscopical examination showed the characteristic changes of
myositis ossificans.
Case VII. — Round-celled sarcoma, involving omentum, colon, and
a loop of small intestine. The diagnosis was made by Dr. Willy Meyer,
and confirmed by exploratory laparotomy and microscopical examina-
tion of a portion removed by Dr. F. Schwyzer, pathologist to the Ger-
man Hospital. The toxins were begun in September, 1894, and con-
tinued for about four months. The tumor slowly diminished in size
and finally disappeared. A year later several calculi were removed
from the gall-bladder, with no evidence of a tumor to be found.
The patient was in perfect health four years after treatment.
Case VIII. — Inoperable angiosarcoma of the breast, treated in
spring of 1895. The growth became sufficiently reduced in size to
be easily removed. The patient was well when last seen, about six
months later.
Case IX. — Recurrent, spindle-celled sarcoma of the palm of the
hand. The growth entirely disappeared under two months' treat-
ment. The patient remained well for about two and one-half years,
when there was a local recurrence. This at first responded to the
toxins, but later they evidently lost their control. Amputation of
the arm was advised. The patient refused operation and chose the
Christian Science treatment for a period of eight months, during
which time the tumor increased from the size of a small walnut to
that of a cocoanut, and extended nearly to the elbow. Amputation
just below the shoulder-joint was performed, but with no hope of doing
more than removing the foul and sloughing mass, as evidence of
generalization had already appeared. Death occurred about four
months later.
Case X. — Recurrent, spindle-celled sarcoma of the thigh and groin
in a female, aged forty-eight years. The tum.or was partially removed
in March, 1896, at the New York Hospital, by Dr. Bull. A large
mass remained in the inguinal region, and there was marked ccderaa
of the whole leg. The toxins were begun on May 30, 1S96, and con-
tinued for about three months, at the end of which time the tumor
had entirely disappeared and the left leg had become normal in size.
The patient remained well for about a year, when she had a local
TREATMENT OF INOPERABLE SARCOMA. 33
recurrence. The toxins were again administered with temporary im-
provement, but later the disease returned and proved fatal in less than
a year.
Case XI. — Spindle-celled sarcoma of the iliac fossa, probably start-
ing in the ilium. The patient, Mrs. D., aged forty years, first noticed
a growth in the right iliac region in the early part of 1895. This in-
creased steadily in size, until in October, 1895', exploratory lapar-
otomy was performed by Dr. Johnston, of Boston. The tumor was
about the size of a cocoanut, attached to the ileum as well as to the
abdominal wall, and was totally inoperable. It seemed to start from
the crest of the ilium. The diagnosis of spindle-celled sarcoma was
made by Dr. W. F. Whitney, of the Massachusetts General Hospital.
The treatment with the mixed toxins was begun by Dr. Farrar Cobb,
of Boston, in November, 1895. ^^ ^ letter the doctor stated that at
the end of six weeks' treatment the growth had entirely disappeared.
In May, 1896, six months later, the patient came to me with a well-
marked recurrence, extending from the crest of the ilium nearly to
the level of the umbilicus and as far to the left as the median line.
The toxins were again begun and continued, with intervals of rest, for
three months, when the patient was discharged from the hospital for a
few months' rest. When she left the tumor was less than one-fifth of
its original size. She was readmitted to the hospital in November.
The tumor had increased considerably in size during the interval of
rest, but under the treatment began to diminish rapidly. She left
the hospital in June, 1897, after six months, when the tumor had
markedly decreased in size, and her general health was good. Owing
to a change of address, I was unable to trace her, and believed that she
had probably died, until I received a letter in December, 1900, three
years after the cessation of treatment, more than four years from the
beginning, in which she stated that she had been in good health and
been supporting the family during the entire time. She had noticed
no evidence of a return of the growth.
Case XII. — Inoperable sarcoma of the sacrum. The patient, male,
aged thirty-eight years, had a rapidly growing tumor in the upper por-
tion of the sacrum, which could easily be felt on rectal examination.
His weight had fallen from 175 pounds to 134 pounds within three
months. He had lancinating pains in the legs, with marked lameness.
The clinical diagnosis of sarcoma was made by Dr. Francis P. Kinni-
cutt, and confirmed by physicians and surgeons who examined him at
St. Luke's Hospital. No microscopical examination was made. The
Am Surg 3
34 COLEY,
toxins were begun in May, 1S95. The injections in this case were all
made in the gluteal region, remote from the tumor. The prognosis
given was extremely bad. However, he began improving immedi-
ately after the beginning of the treatment, and had gained 28
pounds in weight two months later; his lameness had entirely dis-
appeared, and six months later no trace of the tumor could be
detected on rectal examination. The patient was in perfect health,
weighing 175 pounds when last seen, nearly four years after the treat-
ment.
Case XIII. — Inoperable sarcoma of the iliac fossa. E. S., male,
aged fourteen years. A year and a half previously he had been
dragged under a trolley car, causing contusions about the pelvis. In
January, 1895, he began to feel pain in the right groin, and a tumor
soon developed in the right iliac fossa. Exploratory laparotomy by
Dr. George R. Fowler, of Brooklyn, on March 7, 1897, showed a
vascular tumor, filling up the whole right iliac fossa, extending up-
ward three inches above the crest of the ilium and Poupart's ligament.
The tumor was so vascular that Dr. Fowler did not think it wise to
remove a portion for examination. He closed the wound and re-
garded the case as entirely hopeless. The condition continued to
grow rapidly worse after the operation, and on April 10, 1897, the
mixed toxins were given as a last resort. The treatment was carried
out under my direction by Dr. G. H. Davis, of Brooklyn, and con-
tinued for several months. The improvement was immediate and
rapid. At the time it was begun the patient was extremely emaciated,
with marked cachexia, and could not have weighed more than sixty
pounds. Within the next three weeks he was walking about and had
gained at least ten pounds in weight. Examination of the abdomen
showed that the tumor had almost entirely disappeared. The injec-
tions were not made into the tumor, but into the gluteal region and
upper thigh. A few months later he developed a fluctuating swelling
over the ilium behind. The skin became broken and a slight infec-
tion occurred, causing some temperature. I incised the swelling,
evacuating several ounces of degenerated, broken-down tissue. No
bare bone was detected at any time. The curettings of the walls of
the cavity were carefully examined, and not the slightest evidence of
tuberculous disease could be found, practically verifying the original
diagnosis of sarcoma. Another similar operation was performed on
April 10, 1898. The boy has remained in good health up to the
present time, four years after treatment.
TREATMKNT OF INOPERABLE SARCOMA. 35
Case XIV. — Spindle-celled sarcoma of the abdominal wall. The
patient, a girl of eighteen years, was admitted to the New York Cancer
Hospital, December 29, 1897, with a tumor in the lower part of the
abdomen of several months' duration. Exploratory operation per-
formed by Dr. Joseph Brettauer and Dr. George W. Jarmon. A
large mass was found in the abdomen, both intraperitoneal and
extraperitoneal. It was regarded as entirely inoperable. A portion
was removed, and the diagnosis of spindle celled sarcoma confirmed
by Dr. Buxton, pathologist of the hospital. After thirty injections —
the largest dose being six minims — of the filtered toxins the tumor
had entirely disappeared. Very little pain and discomfort resulted
from the treatment, and but four chills occurred during the entire
time. The patient was in perfect health, without recurrence, one and
one-half years later, when she returned to Germany.
Case XV. — Spindle-celled sarcoma of the parotid gland. The
patient, a man of forty years, was a carpenter by occupation. The
tumor was first noticed early in 1897. It grew rapidly, and in March,
1897, was removed by Dr. J. W. Wright, of Bridgeport, Conn. A
second and a third operation were performed in April, but the growth
was found too extensive for removal. The submaxillary glands of the
same side were involved. In July, 1897, the patient was treated with
the mixed toxins at the Bridgeport Hospital for three weeks with little
improvement. He was sent to me by Dr. Wright, August 10, 1897,
for advice and treatment. Believing that perhaps the toxins had not
been pushed to their full limit, I began with daily doses, increasing to
the point of producing a chill and temperature of 103° to 104° nearly
every day. The patient's excellent condition enabled him to with-
stand this severe treatment without loss of weight. He was up and
about the ward the entire time. Some improvement was evident at
the end of two weeks, and, although this was not great, it continued
constant until the middle of October, when the disease had entirely
disappeared. The patient was shown before the New York Surgical
Society in March, 1898, in perfect health. I received a letter from
him, dated April 29, 1900, stating that he was still in good health,
without recurrence, nearly four years after treatment.
Case XVI. — Three times recurrent mixed-celled sarcoma of the
parotid. Female, aged thirty-four years. The tumor had been re-
moved three times by Dr. William T. Bull, and further operation
was deemed inadvisable. Dr. Bull kindly referred the case to me for
treatment with the toxins. The injections were begun in January,
36 CO LEY,
1897, and continued for seven months in very small doses. The
patient was extremely nervous. The tumor became much reduced
in size and very movable, so that most of the tumor could be easily
removed under ether anaesthesia. It would have been impossible to
remove all of it without sacrificing the facial nerve. The toxins were
continued after the operation for a considerable time in very small
doses, just sufficient to produce a chill. The patient is still well and
free from recurrence, more than four years later.
Case XVII. — Twice recurrent round-celled sarcoma of the lower
lip. The patient, a little girl, five years of age, daughter of a physician
in Tacoma, Wash., was referred to me in February, 1897. The diag-
nosis of round-celled sarcoma was confirmed by the pathologists of the
Cancer Hospital, Drs. Dunham and Buxton. In this case the mixed
toxins were used for about six weeks, with the result that the growth
entirely disappeared. The patient has remained well up to the present
time (June 10, 1901), more than four years after the treatment.
Case XVIII. — Eight times recurrent spindle-celled sarcoma of
the chest wall, soft parts. The patient, a surgeon of prominence,
had been operated upon eight times for rapidly recurring spindle-
celled sarcoma of the chest wall, soft parts. The intervals between
operation and recurrence were becoming shorter and shorter and
the character of the growth more vascular and more malignant.
The toxins were begun in November, 1894, and used in small doses
for three and one-half years, with intervals of rest. The patient
gained in weight under the treatment, and continued to perform his
daily duties. Two to three small nodules were removed during the
treatment. He has had no injections now for nearly four years, and
there has been no evidence of return.
Case XIX. — Inoperable sarcoma of the tibia. Male, aged twenty-
five years. The patient was admitted to the General Memorial Hos-
pital in February, 1899, with a recurrent tumor of the tibia, for which
amputation had been advised. A portion of the growth removed had
been examined by Dr. John Caven, Professor of Pathology at the
University of Toronto, and pronounced spindle-celled sarcoma. In
view of this report I believed it wise to give him the benefit of a short
period of toxin treatment before amputating. After about two months
the tumor had apparently disappeared and the injections were discon-
tinued. The tumor disappeared partly by sloughing, and the granu-
lating area left behind became infected with erysipelas, there having
been a case left in the wards some months before. The patient had a
TREATMENT OF INOPERABLE SARCOMA. 37
very severe attack of erysipelas, extending over the whole leg and por-
tion of the body, and after recovering from this he returned home.
He remains in perfect health at the present time, and has continued
his occupation as farmer.
Case XX. — Large chondrosarcoma of the ilium, which disappeared
under the treatment. The patient remained well for seven months,
when a recurrence took place, which proved fatal in about a year's
time.
Case XXI. — Recurrent inoperable tumor of the upper lip. Diag-
nosis, fibro-angioma. Successfully treated with the toxin. The patient
was well when last heard of, over two years after treatment.
Case XXII. — Inoperable epithelioma of the chin, lower jaw, and
floor of the mouth. The growth disappeared entirely under four
months' treatment with the mixed toxins. The patient was well,
without recurrence, when last seen, four years after treatment. The
case was referred to me by Dr. George R. Fowler, of Brooklyn, who
regarded it as entirely inoperable, and the diagnosis had been con-
firmed by a microscopical examination by the pathologist of the
Methodist Episcopal Hospital.
Case XXIII. — Spindle-celled sarcoma of the palm of the hand,
three times recurrent ; the toxins as a prophylactic measure immedi-
ately after last operation. The patient is in good health one and one-
half years after operation. The patient, a boy, aged six years, was
operated upon by Dr J. D. Bryant, in 1898, for acute traumatic
sarcoma of the palm of the hand. A small operation was first per-
formed, and later a more radical one, with removal of the ring and
little fingers and their metacarpal bones. Recurrence quickly fol-
lowed after each operation, and finally, in the fall of 1899, a sarco-
matous tumor appeared in the axillary region. This was removed also
by Dr. Bryant, and as soon as the wound had closed the patient was
referred to me for the toxin treatment. The injections were given in
small doses, two to three times a week, for about three months. The
boy has remained in good health up to the present time, without
recurrence.
The following case of carcinoma is of special interest:
Case XXIV. — Extensive recurrent carcinoma of the breast follow-
ing amputation of both breasts for carcinoma. The toxins were used
continuously for nearly four years. The patient is still alive, four and
35 CO LEY,
one-half years after treatment. The patient, ^Irs. W. H., aged fifty-
six years, was operated upon by Dr. Maurice H. Richardson, of Bos-
ton, for carcinoma of both breasts October 8, 1895. Recurrence was
first noticed in June, 1896, nine months after the primary operation.
Dr. Richardson advised against further operation and referred the
patient to me for opinion as to the propriety of using the toxins. I
stated that I believed the treatment would prove of only temporary
value and might have no effect. I urged the removal of the carcino-
matous area, which at this time was about three to four inches in size,
infiltrating the skin, and, as soon as the wound was healed, to begin the
toxins in the hope of delaying recurrence. Dr. Richardson removed
diseased area November 27, 1896. On January ist, before the wound
had entirely healed, new nodules appeared in the outlying skin near
the anterior axillary line. The toxins were begun on January 10,
1897, and continued in small daily doses for one month. The small
nodules in the skin disappeared. After a short interval of rest her
general health was much improved compared to what it was prior to
the beginning of the treatment. She returned to her home in Massa-
chusetts, and, with occasional intervals of rest, the treatment was con-
tinued in moderate doses upward of three years. On three or four
occasions some minute localized skin infiltrations, not more than one-
fourth inch in diameter, were removed under cocaine. About a year
ago she developed ascites, and has been tapped by Dr. Richardson a
number of times. No tumor has been felt in the abdomen, although
it is quite possible that generalization of the disease has taken place.
The fact remains that life has been unquestionably greatly prolonged
by the continued use of small doses of the toxins in a most unpromis-
ing case of double recurrent carcinoma of the breast.
This case is of great interest, as it shovv^s that in certain con-
ditions the toxins may be used to advantage even in carcinoma,
especially as an aid to partial operation or as a prophylactic
measure against recurrence.
Another case of rapidly growing recurrent carcinoma of the
breast in a comparatively young woman, aged forty-two years,
with involvement of axillary glands, was kept in good health,
with almost complete control of the disease for nearly two and
a half years by the administration of small doses of the toxins
two or three times a week.
TREATMENT OF INOPERABLE SARCOMA. 39
While at the time of my report in 1898 eight of my own cases
had remained well from three to six years, I am now able to
report fifteen cases now passed the three-years' limit. Of these,
two have recurred three and one-fourth years after treatment,
and the other eight years, one dying of metastasis and the
other of local recurrence.
All the cases comprising the foregoing series were hopeless,
inoperable cases, and the diagnosis was confirmed by the micro-
scope, with two exceptions, and in these the history of the case,
together with the clinical appearances, made the diagnosis of
sarcoma unquestionable. The type of the tumor in the fifteen
cases that passed the three-year limit was as follows :
Spindle-celled sarcoma . • . . . . . . . . .8
Round-celled sarcoma .......... 2
Mixed-celled sarcoma . . . . . . ... . .2
Epithelioma ............ i
Sarcoma (clinical diagnosis only) ........ 2
It is worthy of special note that two of the successful cases,
now well three and three-fourths and four and one-fourth years
respectively, are sarcoma of the parotid gland. Butlin, in his
last edition of Operative Treatment of the Parotid Gland, states
that "up to the present time there are very few instances of
cure by operation of undoubtedly malignant disease of the
parotid." In the author's two cases treated by the toxins the
diagnosis was not only confirmed by a competent pathologist,
but further by a history of repeated recurrence after operation.
Another case still is also worthy of special mention, inasmuch
as it shows that the toxins may be taken for long periods of
time without harm. The patient, a well-known physician, with
eight times recurrent spindle-celled sarcoma of the soft parts of
the chest (anteriorly), was treated with small doses of the mixed
toxins, with varying intervals of rest, for upward of two years.
The patient regained his usual health, and has now been per-
fectly well over six years from the beginning and four years
since the cessation of the treatment. The tumors, while origi-
nally pure spindle-celled, were becoming more mixed with round
cells and more vascular with each recurrence. In other words,
40 COLEY,
the disease, as so often happens, was increasing in malignancy
until the toxins were begun.
In addition to these fifteen cases that have passed the three-
year limit, eight were mentioned in which the tumors disap-
peared entirely. One, a spindle-celled sarcoma of the abdominal
wall, was well one and one-half years, when the patient returned
to her home in Europe and was lost sight of. Another, an
extensive round-celled sarcoma of the iliac fossa, was well one
year, and then lost sight of. A third, a spindle-celled, recurrent
sarcoma of the leg, is now in perfect health, without recurrence,
nearly two years after treatment. A fourth, a twice recurrent
spindle-celled sarcoma of the palm of the hand, disappeared
under the toxin treatment, and the patient remained well two
and a half years, when the tumor recurred. Refusing amputa-
tion of the arm, she was under the care of a Christian Scientist
for eight months, during which time the tumor in the hand
reached the size of a cocoanut and extended above the elbow.
Amputation of the arm just below the shoulder-joint was then
performed, but the patient died of metastasis three and one-half
months later.
A fifth case, a chondrosarcoma of the ileum, of large size,
disappeared, and the patient, after remaining well for seven
months, had a recurrence, which proved fatal in about a year's
time. A sixth, a round-celled angiosarcoma of the breast, was
well six months later, when the patient was lost sight of. A
seventh, a recurrent fibro-angioma of the lip, was well when last
heard of, over two years after operation ; and an eighth case, a
spindle-celled sarcoma of the thigh, disappeared, but after a
year's time recurrence took place locally and in the groin,
which no longer yielded to the treatment.
In addition to these personal cases I will mention two other
cases in which I directed the treatment, although it was carried
out by another surgeon. One case (Johnson's), a large spindle-
celled sarcoma of the pharynx, entirely disappeared, and the
patient was well more than six years later. The second (Storr's,
of Hartford), an inoperable sarcoma of the breast and axilla, dis-
appeared under seventy-six injections of the mixed toxins, and is
TREATMENT OF INOPERABLE SARCOMA. 4I
now well more than four years after treatment. The diagnosis
in both of these cases was confirmed by microscopical examina-
tion ; in the latter case by the highest authority in this country,
Prof. William H. Welch, of Johns Hopkins University.
The results of this method during the last two years give no
reason to change the conclusions expressed in earlier papers.
Further experience has confirmed the opinion that spindle-celled
sarcoma yields far better results than any other variety, although
there have been a sufficient number of round-celled cases success-
fully treated to make it advisable to give every inoperable case
the benefit of a brief trial. If no improvement has occurred at the
end of three or four weeks, with daily injections, I do not believe
the treatment is likely to prove successful. If improvement does
occur, the injections should be continued either until the tumor
has entirely disappeared or it has become evident that the toxins
have lost their inhibitory influence. The toxins may be given
for long periods in moderate doses without harm to the patient.
The risks of the treatment are practically ;///, provided proper
precautions are observed. In upward of 200 personal cases
there have been but two deaths, both of which occurred more
than five years ago. The percentage of probable cures depends
largely upon the type of the cell, varying perhaps 3 to 4 per
cent, in the round-celled to nearly 50 per cent, in the spindle-
celled.
Thus far no permanent successes have been obtained in mel-
anotic growths nor in lymphosarcomas of the neck. I believe
that the toxins administered in small doses immediately after
primary operations for sarcoma offer a most valuable prophy-
lactic measure against future recurrence.
The results thus far seem sufficient to warrant advising the
treatment as a routine measure after all operations for primary
sarcoma. While the treatment is not recommended in carcino-
matous growths, it has been the experience of the writer that
in many cases the toxins exert a marked inhibitory influence
upon carcinoma, although this influence is rarely curative. The
only cases of carcinoma in which the toxins are likely to prove
of much value are, I think, those in which they are used after
42 TREATMENT OF INOPERABLE SARCOMA.
primary or secondary operation as a prophylactic against recur-
rence.
Up to the present time sufficient experience is lacking to
justify one in making any definite statements as to how much
may thus be accomplished. I still believe that the action of the
toxins upon malignant tumors is the result of some infectious
micro-organism, and this view is strongly supported by the
recently expressed opinion of Czerny.
THE INFLUENCE OF MENTAL DEPRESSION ON THE
DEVELOPMENT OF MALIGNANT DISEASE.
By JOSEPH D. BRYANT, M.D.,
NEW YORK CITY.
Pericles, about five hundred years before the birth of Christ,
uttered the following: " One sorrow never comes but brings an
heir that may succeed as his inheritor."
It cannot properly be assumed that this distinguished Greek
had in view the topic now before us when he uttered this dis-
tinctive truism.
However, it is not impossible, even at this early date, that
Pericles' wise comprehension of things, supplemented by the
outcome of the painstaking heed of Hippocrates, his colaborer
in public good, might not have exercised a prompting influence
in the giving birth to this expression.
The ancient medical writers, beginning with Galen, who was
born A.D. 132, taught that cancer was dependent on " black
bile," which latter in Greek is synonymous with melancholia.
Therefore, the causal association of cancer with mental depres-
sion, the handmaid of melancholia, is easily understood, and
the birth of the idea in this connection could hardly have been
otherwise than quite spontaneous.
Nowhere in their writings do we find the statement that can-
cer arises from any form of mental perturbation — a fact quite
inevitable, since at this time no discrimination could be made
between the effect of the worry attendant on the presence of
cancerous disease and that underlying the brooding over the
wrongs, the griefs, and the anxieties of the period.
If Galen, or one of his followers, had been asked whether
cancer could develop as a result of the mental burden imposed
44 BRYANT,
by human cares and griefs, he would doubtless have replied
that if the melancholic state predisposed to cancer it would be
quite natural for an individual suffering from melancholia to
emphasize the darker side of things, and be correspondingly
unhappy.
Curiously enough, we find something akin to this reasoning
in modern literature. Virchow quotes Banos with approval as
stating that the depression which is often seen to precede can-
cer of the stomach may be a part of the disease.
In following up the statements of the various standard writers
of the early middle ages we note a strict adherence to the
Galenic view of cancer. But early in the sixteenth century a
change in this respect appears. Instead of giving but a single
cause for cancer, we find authors mentioning contributing
factors, such as trauma, improper diet, etc. Still, we do not
as a rule find any allusion to the causative influence of mental
depression.
The first mention of this causative element which we have
encountered is by Ambroise Pare (born 1510). This noted
author does not, indeed, state that there is a mental factor in
the etiology of cancer, but he does say unquestionably that
mental perturbation, anger, and the like make a cancer " more
fierce and raging," while under the head of treatment he insists
that the patient must eschew fasting, watching, sorrows, cares,
and mourning.
At least three of Fare's contemporaries mention a mental ele-
ment in the causation of cancer. Thus Roderic de Castro (1628),
who wrote an elaborate monograph on diseases of women, gives
among the causes of scirrhus of the breast, " cares, watching,
grief," and later, describing cancer of the uterus, he states that
"grief, fear, anxiety, dejection," etc., may be among the causes.
Vigierius (1659), who is said to have written a monograph on
tumors, states in his work on medicine and surgery that among
the causes of cancer are " violent emotions, excessive vigils, and
affections of the mind."
Mercurialis (1530) also enumerates grief and fear as causes of
cancer.
INFLUENCE OF MENTAL DEPRESSION ON DISEASE. 45
The simplest explanation of the appearance of this idea in
the mediaeval literature is probably the gradual recognition of
the fact after the revival of learning that there were other causes
of diseases beside the " humors." Since grief, fear, and, in gen-
eral, the painful and depressing emotions, came to be recognized
as causes of disease in general, it would be natural to extend
this etiology to cancer, the more readily because of its univer-
sally recognized association with the melancholic habit.
Notwithstanding these isolated mentions of a mental cause
for cancer, the great majority of writers continue to ignore its
importance, as in the early past. We have been able to find
but a few clean-cut exceptions to this position.
J. Hoffman (1660) goes very fully into the matter. In the
chapter on ulcers, including cancer, this author speaks of pro-
longed grief and poignant sadness, and even of unforeseen terror
as important factors in the etiology of cancer. He explains the
connection between these emotions and cancer by the fact that
the former are well calculated to confine the secretions and cause
stagnation and inspissation of them. In this manner prolonged
sadness leads to the production of scirrhus of the pancreas,
mesentery, and liver. Sudden and unexpected terror may cause
a suppression of the milk, which, stagnating in the lactiferous
ducts, may generate a scirrhus of the breast.
Von Swieten (1775) enumerates among the causes of cancer
an atrabiliary disposition of the blood or bile. The atrabilis^
according to the ancient physicians, dependent on the inspissa-
tion of blood or bile, especially in the abdominal viscera, pro-
duces astonishing anguish and grief, leading to scirrhus and
cancers. Doubtless the exploitation of a mental origin of can-
cer by these eminent medical teachers is largely responsible for
the fact that reference to such origin begins to be more frequent
in standard authors.
The next prominent champion of the mental origin of cancer
appears to have been Sir Astley Cooper, who, in writing of the
influence of the mind in predisposing to scirrhus, expressed
himself substantially as follows :
Anxiety of mind, tendency to the presence of slow fever, and
46 BRYANT.
suppressed secretions are the predisposing causes of the com-
plaint. A mother watching with anxiety a near and dear rela-
tive in sickness, deprived of her natural rest and inattentive to
the deviation from health in her own person, is afterward affected
with this disease. A person the prey of disappointment from
reduced circumstances and struggling against poverty, when her
prospects begin to brighten finds a malignant tumor in her
breast. A costive state of the bowels, a dry skin, and a paucity
of other secretions attending this anxious state of mind lay the
foundations of the destructive process that awaits her.
The details of this statement are given quite in full, not only
because of the great eminence of their author, but also because
the extended scope of their presumptive action includes the
common depressive activities of everyday life.
Chomel, the French clinician, and Lobstein, a German bac-
teriologist, are reported to have recognized the mental origin,
and the latter is stated to have theorized extensively regarding
the rationale of its causative relationship.
We have not as yet succeeded in finding the passages to
which subsequent authors allude.
Boyle and Laennec accepted the affirmative side of the con-
troversy. At a little later period we note the first active oppo-
sition to the mental theory, Velpeau and Lebert both stating
their unqualified disbelief in the existence of such a relation-
ship. But authorities like Virchow, Paget, Walshe, and some
of their eminent contemporaries gave a qualified allegiance to
the passive side of the question. Also, the same idea is affirmed
by Rokitansky, Scanzoni, and others.
The foundation of the different phases of the contention rest
on the beliefs: (i) That cancer may result from the direct influ-
ence of mental depression ; (2) that cancer may arise indirectly
from mental depression, because of the defective nutrition at-
tendant upon it; (3) that mental depression exercises in no
respect influences that admit of sufficient proof to warrant
serious discussion.
Incidentally, it is proper to mention at this time that Crook-
shank, writing in 1898 on "Congenital Observations of the
INFLUENCE OF MENTAL DEPRESSION ON DISEASE. 4/
Epiblast in an Insane Man," offered the suggestion that since
the central nervous system, no less than the skin and its ap-
pendages, is of epiblastic origin, one might be justified in
accepting the clinical fact that cutaneous abnormalities fre-
quently indicate the insane diathesis.
Regarding the first proposition, viz.: that cancer results from
the direct influence of mental depression, Hughes has quite
recently written repeatedly in the St. Louis Medical and Surgical
Journal on this phase of the topic. He is disposed to regard
the fatal affections of the late General Grant and of Napoleon
I. as directly dependent on the complicating reversal of busi-
ness ventures in the former and political disaster in the latter
instance. However, he is frank enough to say that his mental
theory was received with ridicule by some of the profession
and with disfavor by nearly all.
Later, Rohe has written in the Fhiladelpliia Medical Times,
taking a position similar to that of Hughes. Kohler, writing
in 1853, enunciates sudden and persistent grief and care of
all kinds as apparently justifiable causes for cancer in many
instances.
Willard Parker, in 1875, submitted the analysis of nearly 400
cases of cancer of the breast in women, frequently attributed
to the mental affection as an exciting cause. In fact, he reports
that "j^ of the cases had been subject to much mental affection,
care, or sorrow.
Snow, 1893, believes that of all the causes of cancer, neu-
rotic agencies are the most powerful, remarking that idiots and
lunatics are remarkably exempt from this infliction. Snow
cites 156 cases in which he regards mental depression as the
dominating cause of cancer. In support of this is quoted the
fact of the rapid evolution of cancer in Strasburg after the
bombardment. However, another reason for this will be men-
tioned later.
Regarding the second proposition, viz. : that cancer may arise
indirectly from mental depression, because of the defective
nutrition attendant upon it, Virchow, writing in 1867, in dis-
cussing thoroughly the neuro-pathological theory of the origin
48 BRYANT,
of tumors, especially of cancer, says that the evidence sub-
mitted under this head is weak. He approves of the idea ad-
vanced by Barras, that these mental states may themselves be
a part of the prodromes of the cancerous disease. He further
states that cancer in general, and cancer of the stomach in par-
ticular, is more common in the well-to-do than in the indigent,
so that one might conclude that the more nervous class of
people is the more exposed to cancer. This explanation, how-
ever, is very problematic, and would not hold good for tumors
as a whole. Beside, a weakness of the nerves does not imply
a weakness in general nutrition.
In any case, the influence of the nerves could do no more
than lessen the vitality of the tissues, which influence would be
equally apparent in other disorders of nutrition, and could,
therefore, be only a simply predisposing cause.
It seems to us quite probable that the influence of mental
disturbance on the bloodvessels and in the nutrition of the
parts incident to the bombardment of Strasburg will account
much more rationally for the evolution of cancer thereafter than
fear alone can do.
Paget (1865), in speaking of the occurrence of cancer from
mental distress, expressed the belief that the numerical evidence
to uphold such a view is lacking. Nor was it apparent that joy-
ousness and prosperity were safeguards against cancer. He re-
garded the depressed nutrition incident to the mental state as
weighty and the fatal cause of cancer development in these cases.
Picot (1877) regards the influence on the nutrition of mental
emotion as of importance in the outbreak of cancerous disease
in those predisposed by heredity or otherwise.
Walshe (1846), in opposing the neurotic theory of cancer,
points out the facts that authors who dwell most strongly on
this mode of formation of cancer, curiously enough fix on the
middle ranks of society as those furnishing the least amount
of cancerous disease, yet these are precisely the classes in which
reverses of fortune most frequently occur, and in which mental
anxiety, inseparable as it is from professional and commercial
pursuits, must be strongest and most constant.
INFLUENCE OF MENTAL DEPRESSION ON DISEASE. 49
Luecke and Zahn (1896) regard the influence of mental emo-
tions as operating on the production of cancer by diminishing
the vitality only in a general way.
Fere, in his recent work on the pathology of emotions (1899),
states regarding the direct effects of nervous influence on
cancer, that observations of this sort are rarely of satisfactory
clearness when the organ involved is one whose destruction
is partial. But when the tumor affects the brain, it is not very
rare to see explosion of the pathognomonic symptoms pro-
voked by moral emotion. This can be said only when the
emotion acts, not upon the tumor, but upon the bloodvessels
which modify the volume.
The third contention, that mental depression exercises in no
respect influences in the causation of cancer that admit of
sufficient proof to warrant serious scientific discussion, has
many powerful and gifted advocates.
Lebert, writing in 185 1, says substantially, under the head of
etiology of cancer :
The influence of the moral agencies in the production of
cancer has been admitted by all the authors who have written
up this subject. But when we study the observations on which
the view is based we do not find anything beyond impressions
to sustain it. He had investigated a large number of cases in
regard to the operation of this cause, but had found propor-
tionally very few in which intense and profound vexation had
preceded the appearance of cancer. On the contrary, he found so
many patients without any history of this sort that he could not
believe the occurrence of such causes was anything more than
coincidence. He referred to the well-known fact that cancer is
common among domestic animals, and inquired if we were to
regard them as subjects of sorrow. Finally, he said, " Nothing
is less proven than the influence of depressing emotions in the
etiology of cancer."
Velpeau, in 1858, disapproved of the influence of mental
perturbation in the following strong terms :
" However much invoked by the public as causes of cancer,
they play absolutely no part in its production, and if we take
Am Surg 4
50 BRYANT,
such things into account, it is rather to humor the patient than
to satisfy a scientific argument."
Birch-Hirschfeld (1885) places the subject of the origin of
cancer from mental distress in the same category as the dietetic
origin ; that is to say, the question of " such etiology does not
admit of scientific discussion."
Williams (1894) was unable to concur in this theory, and
stated that the majority of cancer patients whose life-history he
had investigated appeared to have been less exposed to depress-
ing influences of this kind than most women of corresponding
age in the general population. The fact that Perls, Billroth,
Zeigler, and Lancereaux make no mention of these influences in
the etiology of cancer cannot be regarded as oversight, but
rather as a silent expression of their belief that such causes
were not entitled to the dignity of notice.
We have quoted more extensively than we had intended at
the outset, but justify this course since it places before us the
consensus of able opinions and incidentally many of the argu-
ments employed in forming them.
As will be noticed from the statements already quoted, the
great preponderance of scientific opinion favors the idea that
rnental depression at the most exercises only a predisposing
influence in the causation of cancer; also, that this influence is
the natural product of the* defective nutrition incident to the
perturbation itself.
When it is recalled how frequently the secondary manifesta-
tions following operations for cancer appear to be facilitated,
both in promptness of appearance and after progress, by
increased vulnerability, due to imperfect nutrition, we are dis-
posed to favor the belief that impaired nutrition from any cause
may encourage malignant development.
In the further discussion of this topic, under the phase that
cancer may result from the direct influence of mental depres-
sion, it appears to us not unwise to make the following division
of this class of cases: i. Cases in which mental depression is
not associated with the idea of cancer. 2. Cases in which
mental depression is associated with the idea of impending
INFLUENCE OF MENTAL DEPRESSION ON DISEASE. 5I
cancer of primary or secondary occurrence. 3. Cases in which
the depression is the outcome of common causes.
Regarding it as reasonable to assume that if mental pertur-
bation cause malignant disease, malignant diseases should char-
acterize the history of patients suffering from the effects of
mental perturbation, we addressed our attention to the history
of cases of melancholia.
Inasmuch as mental depression from all causes leads to mel-
ancholia in numerous instances, it seemed to us proper to
investigate the records of asylums for the insane, with the
view of ascertaining (i) the number of admissions for melan-
cholia and the cause assigned for its development : also, the
death-rate in those cases from malignant disease ; (2) the rela-
tion to malignant diseases of the death-rate of the insane and
that of the public at large.
While there is no reason to believe, nor has it been claimed,
that mental depression dependent on the fear of impending
cancer is more potent as a cause than are the common pertur-
bations of everyday life, still it cannot be amiss to refer to the
idea, notwithstanding the fact that no direct kinship can exist
between any peculiar kind of mental perturbation and its
sequels ; that is, the fear of cancer can no more cause it than
can the fear of tuberculosis.
In the Nineteenth Annual Report of the State Hospital for the
Insane, at Warren, Pennsylvania, the following interesting facts
bearing on the causes of mental depression as producing insan-
ity appear. Only those of fifteen years and upward are admitted
to the institution. Anxiety from various causes, domestic and
financial troubles, unrequited love, etc., are the alleged causes
of insanity in 508 (ii-39 + per cent.) of the admissions during
the last twenty years. It appears that of the 4458 admissions,
745 (16.71 + per cent.) of the number suffered from melan-
cholia, of which number 402 were females and 343 males. Only
5 (i in 891) of the entire number (4458) died from malignant
disease, and of these one, a male, died from cancer of the
stomach ; in the remainder, the females, death was caused in
3 instances by cancer of the breast, and in i of the liver.
52 BRYANT,
There is nothing in the report to show that any one of the melan-
cholic cases died from cancer, and if it should happen that all
5 were melancholic cases, then the death-rate would be very-
much less per cent. (0.67 -]- of i per cent.) in melancholia from
perturbation than it now appears to be from cancer among the
people at large (6.42 per cent.).
In this immediate connection it is important to note the sig-
nificance of the following summary, prepared for me a few days
ago by Dr. Roger S. Tracy, the eminent statistician of the
Health Department of Greater New York. The computations
of Dr. Tracy show the following comparative relations between
the total death-rate and that from cancer in the sexes above
fifteen years of age in England and Wales, Scotland, Paris, and
New York, for the ten-year period of 1889 to 1898 inclusive:
Ten Years, 1889-1898 Inclusive.
Great Britain, Paris, and Neio York Combined.
Deaths of males, total and from cancer, fifteen years and upward.
England and "Wales
Scotland .....
Paris ......
New York .....
10.5,257 2,226,389
Males 15 and over. Per cent, of cancer on total, 4.73
Deaths of females, fifteen years old and upward, for ten years, 1889-1898
inclusive.
Cancer. Total deaths.
England and Wales . . .134,106 1,597,092
Scotland 17,986 253,650
New York 6,904 111,993
Paris 15,928 176,236
Cancer.
Total deaths.
81,048
1,667,011
10,759
227,485
9,386
200,144
4,064
131,749
174,924 2,138,971
Females 15 and over. Per cent, of cancer on total, 8.18.
Grand Total.
Cancer.
Total deaths.
Per ct. of cancer
on total.
Males, 15 and over
105,2.57
2,226,389
4.73
Females, " " "
174,924
2,138,971
8.18
280,181 4,365,360 6.42
INFLUENCE OF MENTAL DEPRESSION ON DISEASE. 53
The meaning of these figures is of vital consequence in more
than a single comparative sense. It demonstrates not only the
relative infrequency of cancer in insane patients, but also the
startling frequency of death from cancer among the people at
large ; also that the female sex suffers from cancer nearly twice
as frequently as the male, apparently irrespective of any partic-
ular form of insanity.
Prompted by the results of the general statistical outcome
just stated, we determined to investigate along a special line of
observation, and, with this purpose in view, consulted numer-
ous annual reports of insane institutions in various parts of the
country.
Unfortunately, the plans of compilation of these institutions
in many instances were entirely devoid of any practical scien-
tific outcome, it seemingly being regarded as more important to
report definitely the number of bushels of potatoes eaten than
the number of patients cured. It may not be impossible, in
many institutions dependent upon the public coffers for sup-
port, that political expediency is regarded a more potent factor
of capacity than that of scientific attainment.
However, we collected 67,718 cases of insanity, of which
15,031 (22 + per cent.) were of the melancholic type. Of this
number 53 + per cent, were male and 46+ per cent, female
melancholies, showing in this instance an excess of 7 + per
cent, of the male sex. The deaths from cancer (114) in the
total number (67,718) were 0.168 + per cent., a rate far less
than that of the general public (6.42 per cent.). Of the total
number of deaths from cancer (114)41 (36 — per cent.) were
males and 73 (64 + per cent.) were of the female sex. There-
fore, it is evident that nearly two-thirds of the total number of
deaths from cancer were females, although less than one-half of
the total cases of melancholia were of that sex.
With the idea of ascertaining the comparative frequency of
cancer of the sexes, as modified by the effect on the patients of
perturbing mental influences, as represented by the cases of
melancholia, the records of the male and female departments of
the Manhattan State Hospital for the Insane were, through the
54
BRYANT,
courtesy and co-operation of the efficient superintendents, Drs.
MacDonald and Dent, interrogated for a period of ten years
following 1890. Only patients above 15 years of age are con-
sidered.
Female Department of Manhattan State Hospital for Insane.
Cases of melancholia admitted since 1890.
Year. '^
0. of cases
Died of malig-
Died of otlier
admitted.
nant disease.
diseases.
Oct. 1, 1890, to Sept. 30, 1891 .
326
0
59
1892 .
406
1
69
1893 .
431
3
84
1894 .
479
2
104
1895 .
581
3
101
1896 .
543
0
110
1897 .
344
2
81
1898 .
348
3
50
1899 .
296
0
49
1900 .
380
4
65
4134
18
772
Death-rate, ^/j -f- of 1 per cent, in ra
elancholia
Other forms of insanity since 1890.
Year.
No. of cases Died of malig- Died of other
■
admitted.
nant disease.
diseases
Oct. 1, 1890, to Sept. 30, 1891 .
368
0
106
1892 .
391
3
111
1893 .
402
1
209
1894 .
311
0
116
1895 .
388
1
124
1896 .
327
0
175
1897 .
418
2
159
1898 .
472
0
185
1899 .
427
2
170
1900 .
411
1
181
3915 10 1536
Death-rate, V4 + of 1 per cent, in other forms of insanity.
It will be noted at once that the death-rate from cancer in the
female patients suffering from melancholia is nearly twice as
large as when associated with other forms of insanity in the
same sex.
INFLUENCE OF MENTAL DEPRESSION ON DISEASE. 55
An examination of the males for the same period revealed
the following interesting exhibit.
Male Department of Manhattan State Hospital for Insane.
Cases of melancholia admitted since 1890.
Year.
Oct. 1, 1890, to Sept. 30, 1891
1892
1893
1894
1895
1896
1897
1898
1899
1900
No. of cases Died of malig- Diei] of other
admitted.
iiant disease.
diseases
258
0
35
372
1
47
323
0
62
244
1
54
232
1
61
346
0
63
328
1
48
309
0
30
268
1
32
339
2
34
3019
466
Death-rate, Vi — of ^ P^^" ^^^^- i" melancholic patients.
Other forms of insanity admitted since 1890.
Year No. of cases Died of malig- Diedofotlier
admitted. nant disease. diseases.
Oct. 1, 1890, to Sept. 30, 1891
. 463
1
204
1892
. 442
3
238
1893
. 517
0
201
1894
. 408
3
229
1895
. 489
1
256
1896
. 486
2
281
1897
. 440
0
221
1898
. 439
0
258
1899
. 378
0
225
1900
. 332
1
235
4394
11
2348
Death-rate, Vt + of 1 per cent, in other forms of insanity.
It appears from these figures that melancholia (^ — of i per
cent.) in the male exercises no distinctive influence on the death
rate as compared to other forms of insanity {}( -{- of i per
cent.).
It likewise appears (i) that the various forms of mental per-
turbation are common causes of tnelancholia, and that the male
suffers from melancholia from these causes quite as frequently
as the female ; (2) that in the female cancer is associated with
56 INFLUENCE OF MENTAL DEPRESSION ON DISEASE.
melancholia (4 -- of l per cent.) about twice as often as in the
male (^ — of i per cent.), also nearly twice as frequently as with
"other forms of insanity" in either sex {}( -\- of i per cent.) in
each ; (3) and to repeat that cancer in the male is not practi-
cally fatally associated with melancholia oftener {}( — of i per
cent.) than with other forms of insanity (^^ — of 1 per cent.).
It is, consequently, evident that for some reason the death-rate
from cancer in melancholia in female cases (f -r of i per cent.)
is much greater than in the opposite sex (5^ — of i per cent.).
That the effect of mental perturbation is potent in the male
is evidenced by the fact that melancholia occurs quite as often
(page 51) and perhaps oftener (page 53) for this reason in the
male as in the female sex. However, since cancer happens in
melancholic cases for similar reasons as frequently again in the
female as in the male sex, we must assume, in accounting for
this difference, the presence of the activity of special reasons
in the former, which are no part of the history of the latter sex.
Perhaps the vulnerability incident to the impoverishment of
the blood in melancholia — a condition described by Steele as
constant and potent in these cases — may be of greater measure
or profounder significance in the female than in the male sex.
And, too, the more extended field available for malignant attack
in the female may account for the apparent differences in the
degree of infliction.
At all events, there is nothing probable in the aforegoing to
warrant the assumption that mental depression exercises any
influence in the causation of cancer except through the blood
impoverishment which almost invariably exists in melancholia
(Steele), a change which appears not materially to influence the
outcome in the male, as the percentage of affliction is substan-
tially alike in this sex in all forms of insanity. Hence, it ap-
pears that the preponderance of malignant manifestations in the
female should be attributed rather to the broader field of attack
than to any form of special vulnerability.
THE CAUSE OF CANCER/
By THOMAS S. CULLEN, M.D.,
liALTIMORE.
Being interested in the subject of cancer, I have followed the
work in the New York State Laboratory for the last two years,
and learned with interest the results obtained by Dr. Gaylord
and embodied in his lecture at the Johns Hopkins Hospital
and in his paper in the American Journal of the Medical Sciences
for May of this year.
In order to prove conclusively that a given organism is the
cause of cancer it is necessary:
1. To find or isolate the organism.
2. To produce cancer by inoculating the organism into another
body.
3. To recover the organism from the cancer thus produced.
I have had the opportunity of examining some of Dr. Gay-
lord's specimens, and it is certain that the nodules he produced
in the guinea-pig's lungs are cancer. He, however, used peri-
toneal fluid and not a pure culture of the organism, and hence
the first and second requisites are not properly fulfilled. He
cannot exclude the possibility of cancer cells from the patient
having been carried over in the fluid to the guinea-pig, and it is
a well-established fact that cancer cells may be transplanted and
grow. The third requirement is barely touched upon, and no
proof of its successful accomplishment is adduced.
On page 5 1 1 of the journal above mentioned he speaks of
being able to cultivate his germ with " comparative regularity,"
and we are given the medium upon which it grows. And yet
1 Discussion of Dr. Park's paper on " The Cause of Cancer."
58 CULLEN,
no word as to its appearance or behavior on the culture medium
is mentioned. Nor have we a picture of it, although both Plim-
mer's and Sanfelice's organisms are depicted on Plate VII.
This omission is difficult to account for. Further, on page 537,
a list of his injections into animals is found, and here also we
fail to find a single instance where there is conclusive evidence
of a pure culture of a germ being employed.
The major portion of the article is taken up with the exam-
ination of tissues hardened according to different methods; but,
as Prof. Welch pointed out at the Hopkins meeting, we might
argue indefinitely upon the histological changes without making
an iota of progress. In fact, for years one body of men has
been claiming that these peculiar bodies found in carcinoma are
due to cell degeneration ; the opposite faction, that they are
parasites. It is only by cultivating the organism, if there be
any, and then producing the disease afresh with this newly-
found germ, that we can prove the cause of this dread malady.
As a matter of fact, Dr. Gaylord has confirmed the results of
others, but added little or nothing new,^ and the cause of cancer
is still an unknown factor. It is very unfortunate that the sug-
gestion that cancer parasites were floating around in the blood
has led a portion of the daily press to infer that cancer is a
blood disease and consequently that the removal of a cancer
will be useless, as the disease is sure to appear at another point.
Such is certainly erroneous. We know that cancer is not a
blood disease, but that in the early stages it is an entirely local
process ; that it is permanently curable is evidenced by the re-
sults in European and, to come nearer home, in our own hos-
pitals, where patients are living and well years after complete
removal of the growth.
Dr. Gaylord and his associates should in nowise be discour-
aged. Many of the world's most able investigators have been
seeking the same goal, and as yet none has reached it. They
should be encouraged at every point, as in their love for science
• In justice to Dr. Gaylord, it must be added that the above-mentioned article is
a preliminary communication, and that the completed work may solve many of the still
obscure points.
THE CAUSE OF CANCER. 59
they are willing to forego financial prosperity in the hope that
they may eventually rid mankind of this scourge. New York
State is to be congratulated on its wisdom in establishing a
cancer laboratory, and is showing a commendable spirit in
increasing instead of diminishing the support accorded its
scientific men.
Dr. Park (closing the discussion) : I have not told one-half of what
I would like to, but a further paper will be prepared by Dr. Gaylord,
and much more will be published by the Buffalo Laboratory in a short
time. We have done a large amount of inoculation work, but all the
animals have died, and apparently that which was introduced was the
cause of death. We are not yet prepared to report our entire expe-
rience, but expect to do so in the future.
THE CLINICAL VALUE OF BLOOD EXAMINATIONS
IN APPENDICITIS : A STUDY BASED ON THE
EXAMINATION OF ONE HUNDRED AND
EIGHTEEN CASES IN THE GERMAN
HOSPITAL, PHILADELPHIA.
By J. C. Da COSTA, Jr., M.D.,
PHILADELPHIA.
Mr. President and Fellows of the American Surgical
Association : The communication which I have the honor of
presenting to the Association, by the invitation of your Secre-
tary, is offered with no slight hesitancy, for, at first glance, it
must seem somewhat needless to approach a topic already so
familiar to all surgeons, thanks largely to the careful studies
made by Cabot and by Greenough during the past five years.
Still, there are reasons which appear to justify a further consid-
eration of this topic. The fact, for example, that certain of the
blood changes in appendicitis have been either overlooked or
regarded as trivial in comparison with other more conspicuous
features of the blood picture, and the tendency of some clin-
icians to attach undue diagnostic and prognostic significance to
the blood report — these reasons, perhaps, are of sufficient
weight to render the theme less hackneyed than its title leads
one to infer.
Methods and Technique. The conclusions embraced in this
report are based upon data derived from the examination of
1x8 cases of appendicitis in Dr. John B. Deaver's ward at the
German Hospital. All these cases were treated surgically, and
the statistics relating to the blood changes represent the condi-
tion of the blood before operation, usually at the time imme-
diately after the patient's admission to the hospital. The
VALUE OF BLOOD EXAMINATIONS IN APPENDICITIS. 6l
majority of cases were examined but once, and in the few
instances in which multiple estimates were made the data of
the initial examinations only were included in the analysis.
Most of the counts were made by various members of the
hospital's house-staff, a few by myself. The services of Dr. G. P.
Miiller, senior resident pathologist at the hospital, in tabulating
and classifying the clinical histories of the patients, have been
invaluable
The hcEmoglobin estimates were made with a von Fleischl
haemometer, which, for the sake of greater accuracy, was en-
closed in a light-proof box provided with a camera-tube limit-
ing the observer's field of vision to the mixing-chamber of the
instrument. As a rule, a number of different readings were
made by several examiners, and the average of the figures most
closely corresponding taken as the final estimates.
Both the erythrocytes and leucocytes were counted with the
same instrument, a Thoma-Zeiss erythrocyte-pipette, Toisson's
solution being used for diluting the blood, generally in the pro-
portion of I : 200. Zappert's counting-slide, having a ruled
surface equalling that of 3600 of the small squares of the orig-
inal Thoma-Zeiss counting-cell, was employed in nearly every
instance. The erythrocytes in at least 200, and the leucocytes
in not less than 3600 of these small squares, were counted, to
serve as a basis for the calculation of the total number of cells
to the cubic millimetre of undiluted blood.
Differential counts were made only in exceptional instances ; in
those, for example, with a leucocytosis in which the symptoms
did not suggest appendicitis as a factor of the leucocyte
increase. An absence of any important qualitative change
affecting the blood-cells in this disease was thought to justify
the omission of differential counting as a routine step in all
cases in which the symptoms were definite. In those instances
in which the percentages of the different forms of leucocytes
were calculated, the figures represent the average of counts of
at least 250 cells, made from heat-fixed films, stained with
Ehrlich's triple stain, containing acid fuchsin, methyl-green,
and orange-G.
62 DACOSTA,
Classification. From a hjtmatological view-point all forms
of appendicitis may be conveniently classified in two general
groups, purulent and non-purulent. The first group includes
simple catarrhal and interstitial inflammations of the organ,
unattended by abscess formation, by gangrene, and by general
peritonitis, singly or combined. The second group comprises
cases with foci resident in, or primarily arising from, the appen-
dix, with or without a complicating appendicular gangrene and
general peritoneal inflammation. It must be admitted that
such a vague classification as this is useful only in so far as it
relates to the blood changes to be detected by routine clinical
examinations — changes by the aid of which the surgeon en-
deavors to determine the presence or absence of suppuration
and peritonitis, and to trace the progress of the lesion from day
to day.
Of the ii8 cases included in this report, 38 (or 32.2 percent.)
were unattended by pus formation, while in the remaining 80
(or d"]."] per cent.) this condition prevailed, sometimes with and
sometimes without further inflammatory changes. These fig-
ures, of course, do not represent the usual ratio between the
two forms of the disease just specified, since the cases here
collected were not examined in an unbroken, consecutive
series.
The features of the blood changes of greatest clinical interest
in this disease are the anaemia by which it may be accompanied
and the behavior of the leucocytes, the former being sometimes
so decided as to constitute a symptom demanding recognition
and serious consideration, and the latter being of prime in-
terest in relation to the diagnosis and prognosis of the attack.
The Anemia of Appendicitis. Apparently most writers
regard this subject as one of comparatively trivial importance,
for beyond the general observation that in chronic cases, pre-
sumably septic, a variable decrease in the haemoglobin percent-
age and in the number of erythrocytes may occur, the question
thus far has been dismissed with but casual notice. The fact,
however, should not be ignored that the associated anremia may
be so marked as to constitute a symptom demanding careful
VALUE OF BLOOD EXAMINATIONS IN APPENDICITIS. 63
attention, even should it not be of sufficient gravity to retard
convalescence or to endanger the patient's life.
(a) HcBmoglobin. Practically every case of appendicitis, what-
ever its character, shows a variable degree of hiL-moglobin loss,
this decrease occurring with about equal frequency in both the
catarrhal and the suppurative forms of the disease, although in
the latter it tends to become more striking in the individual case.
Speaking in averages, it will be found that the hii^moglobin is
diminished to at least one-half of the normal standard in ap-
proximately I case in every lo (lO. i per cent.), while in an
occasional instance it falls to a figure which operators are
accustomed to regard as perilously low — to 40 per cent, or less
in about 3 cases (2.5 per cent.) out of every 100. The fact that
such low figures are encountered, although but rarely, seems
sufficient to call for a routine haemoglobin test in all patients to
be treated surgically, for should the surgeon meet with such a
profound oligochromaemia in one whose other symptoms de-
mand the use of the knife, the advisability of an operation,
unless imperatively indicated, might appear to him question-
able. Not being a surgeon, I cannot presume to discuss this
technical point, but simply draw attention to the fact as sug-
gestive if not really important. It may be added that, judging
from the meagre data at my command, an extreme haemoglobin
loss does not appear per se to be dangerous, since uninter-
rupted recovery took place in all the three patients of this
series in whom hsemoglobin readings of 40 per cent, or lower
were made. Positive conclusions, however, are scarcely justifia-
ble from so small a number of examinations. Judging from this
series, the average hccmoglobin loss in all forms of appendicitis
is about 30 per cent., the average readings for the 118 cases
being 70.1 per cent, of normal, or 69.1 per cent, for the catar-
rhal, and 70.1 per cent, for the suppurative form.
{b) Erythrocytes. The erythrocyte loss, save in exceptional
instances, is inconspicuous, since in fully 3 out of every 5 cases
(or in 63.5 per cent.) the number of these cells ranges between
4,000,000 and 5,000,000 to the cubic millimetre, while the latter
count is exceeded in about i case in every 10 (or in 12 per
64 DA COSTA,
cent.). The average loss for the 38 catarrhal cases was 16.2
per cent, (average count, 4,186,846), and for the 80 suppurative
cases, 1 1.9 per cent, (average count, 4,400,145), while the most
striking examples of oligocythaemia in the individual case
were practically equal in both forms — 59 per cent, decrease in
the non-suppurative and 58 per cent, loss in the suppurative,
figures corresponding to counts of 2,050,000 and 2,100,000 per
cubic millimetre respectively.
These results tend to show that, contrary to the current view,
patients suffering from catarrhal appendicitis may be found to
be anemic just as frequently as those suffering from forms of
the disease associated with abscess formation and easily recog-
nized symptoms of septicaemia — a characteristic with which I
have been frequently impressed long before this attempt was
made to analyze the statistics of the blood-counts. Perhaps the
fact that the majority of these non-suppurative appendicitides
were of chronic character, occurring in patients whose consti-
tutions, undermined for a long period, were greatly debilitated,
may serve to explain the frequency of anaemia in this variety
of the disease. Thus it appears that this factor of inadequate
blood production is quite as active in provoking anaemia as is
the element of sepsis, which is largely responsible for the blood
destruction in suppurative appendicitis.
(c) Color Index. The color index, or the figure used to indi-
cate the richness in haemoglobin of the individual erythrocyte,
is usually found to be moderately subnormal, from about 0.70
to 0.80 in the great majority of counts. The index for the
total 118 cases of this series averaged 0.82 +,or about eighteen
points below the arbitrary standard, 1 ; in the 38 non-sup-
purative cases it was 0.82, and in the 80 with abscess, 0.79.
The foregoing data apply, of course, only to averages, but they
tend to show that an anaemia of the ordinary secondary type
prevails in appendicitis — that is, one in which the haemoglobin
loss is usually somewhat relatively greater than that of the
corpuscles. In the individual case, however, the index may fall
to quite as low a figure as that commonly found in chlorosis, to
0.53, in one of these cases, for example; or, on the other hand,
VALUE OF BLOOD EXAMINATIONS IN APPENDICITIS. 6 =
it may rise to as high a figure as that which prevails in typical
pernicious an;L'mia, to 1.50 in another case in the series, for
instance.
In cases with severe anitrnia, deformities of shape and size
were commonly noted, but neither nucleated erythrocytes nor
decided evidences of atypical staining were observed. The
number of stained specimens examined, however, was too small
to attach to these remarks any value regarding the occurrence
of erythroblasts and of polychromatophilic cells. There is no
good reason why both should not be found in cases in which
the antX^mia is of suf^ciently grave type. The range of the
haemoglobin and erythrocytes is illustrated by the following
table :
Table I. — Hemoglobin and Erythrocytes.
Haemoglobin,
percentage.
Simple catarrhal and interstitial
forms.
(38 cases.)
Cases with abscess, gangrene, or
general peritonitis.
(80 cases.)
Acute.
Chronic. .
Total.
Acute.
Chronic.
Total.
Above 100 per ct.
90 to 100 "
80 " 90 "
70 " 80 "
60 " 70 "
50 " 60 "
40 " 50 "
30 '• 40 "
1
0
3
4
3
5
2
0
0
0
6
5
8
1
0
0
1
0
9
9
11
6
2
0
0
4
14
26
17
6
6
3
0
0
3
0
0
0
1
0
0
4
17
26
17
6
7
3
Highest,
Lowest,
Average,
102 per ct.
45 "
69
86 per ct.
60 "
72.7 "
102 per ct.
45
69.1 "
98 per ct.
:h8
71.7 "
90 per ct.
48
76
98 per Ct.
38 "
70.1 "
Erythrocytes,
per c. mm.
Above 5,000,000
4,000,000-5,000,000
3,000,000-1,000,000
2,000,000-3,000,000
1
10
6
1
3
13
4
0
4
23
10
1
9
50
12
5
2
2
0
0
n
52
12
5
Highest,
Lowest,
Average.
5,660,000
2,050,000
4,240,389
5,620.000
3,100,000
•4.348,000
5.660,000
2,050,000
4,186,846
5,710,000
2,100,000
4,372,500
5,240,000
4,490,000
4,925,000
5,710,000
2,100,000
4,400.125
The Range OF THE Leucocytes. The numerical fluctuations
of the leucocytes constitute, by all odds, the most important
feature of the blood picture associated with this disease, and
the behavior of these cells has been regarded as a sign, both of
diagnostic and of prognostic value, to interpret with more or
less accuracy the pathological condition of the local lesion and
Am Surg 5
66 D A C O S T A ,
to furnish information as to the presence or absence of com-
plications. To what extent the leucocyte-count can be relied
upon as a dependable clinical sign and to what extent it may
prove misleading in routine clinical work I have attempted to
determine by the following inquiry.
In the catarrhal and interstitial forms of appendicitis, without
abscess or any of its consequences, the number of leucocytes, as
a rule, does not exceed the maximum normal standard (10,000
per cubic millimetre), and, indeed, is not infrequently much
below this figure. In a fairly large proportion of cases, how-
ever, exceptions to this rule must be noted, for counts of
12,000, 15,000 or. rarely, even higher may sometimes be en-
countered. In the present series, 39.4 per cent, of the cases
(15 cases) showed a leucocyte increase ranging between 10,000
and 17.100, the latter being the maximum, while in 60.5 per
cent. (23 cases) the counts were below 10,000, the minimum
estimate being 1600. It may be observed, in passing, that the
maximum count of the individual case of catarrhal appendicitis
is somewhat lower than the average count in the purulent
variety, to be considered later.
It does not seem unreasonable to attribute the majority of
these high counts to the presence of a local non-purulent in-
flammation restricted to the peritoneal covering of the appendix,
since a circumscribed peritonitis of this sort is not uncommon
in this form of the disease, and is quite sufficient to account for a
moderate leucocytosis. In other cases the possibility that the
increase represents simply a blood-finding of the associated
anaemia must naturally be suggested, or, again, that it may be
the result of blood inspissation, for the production of which
copious emesis or purging may have been the factors.
In cases with abscess, gangrene, or general peritonitis, a well-
marked leucocytosis is found in most instances, the majority of
appendicular abscesses raising the count to 15,000 or 20,000 per
cubic millimetre, and sometimes to even a higher figure. It is,
however, a well- recognized fact that should the pus focus hap-
pen to be so effectually walled off" that little or no absorption of
toxic material can occur, such a decided increase may fail to
develop. On the other hand, leucocytosis may also be absent,
VALUE OF BLOOD EXAMINATIONS IN APPENDICITIS,
67
or, indeed, leukopenia may be found, in profoundly septic
patients in whom the effects of the poison have proved so
crippling that reaction is stifled. However active may have
been this factor in the experience of others, in my own experi-
ence it has rarely been found that the patient's resisting powers
were so effectually overcome that leucocytosis was prevented,
for in only two out of my 12 fatal cases (or in 16.6 per cent.)
was a well-defined leucocytosis absent, the counts in these two
cases being 6000 and 11,200 respectively. In the other ten
counts the number of leucocytes ranged from a minimum of
14,200 to a maximum of 58,500, and averaged 19,400 per cubic
millimetre.
Table II. — Fatal Cases.
No.
Haemoglobin.
Erythrocytes.
Leucocytes.
11,200
Remarks.
1
71
4,580,000
2
98
5,420,000
14,600
36 hours after operation.
98
5,460,000
10,200
6 days " "
96
5,430,000
16,800
9 "
"3
88
5,280,000
58,500
4
100
5,120,000
15,200
General peritonitis.
5
85
4,370,C00
22,800
6
75
4,550,000
16,000
7
68
4,470.000
19,600
8
79
3,840,000
21,500
9
5,000,000
6,000
10
95
4,110,000
14,200
Immediately alter operation.
90
4,150,000
20,400
1 day after operation.
ii
75
4,970,000
14,800
12
46
2,760,000
11,600
From the above statements it is natural to infer that the degree
of leucocytosis, as determined by a single examination, cannot be
relied upon as a prognostic sign. If, however, by repeated ex-
aminations a progressive increase in the number of leucocytes
is detected, it may generally be concluded that the pus collec-
tion has become more extensive or that a general peritonitis has
been excited. Such accidents as these were heralded in three
cases of this series by an increase varying from 6600 to 14,000
cells to the cubic millimetre in excess of the number previously
counted. Perforation is usually accompanied by an abrupt
rise in the leucocytes, although it is to be recalled that in
greatly debilitated individuals this increase may be absent, or
indeed, a sudden decrease may occur. Personally, I have not
investigated this question with sufficient thoroughness to war-
68 DA COSTA,
rant definite conclusions as to the behavior of the leucocytes
under these circumstances.
Absence of leucocytosis has also been observed in cases in
which the pus focus is of small extent, but small abscesses are by
no means always associated with low counts, for the intensity of
the systemic reaction provoked by the abscess, and not the ex-
tent of the latter, appears to be the more active determining
factor of the increase.
In the present series the count for purulent cases averaged
17,453, or somewhat less than double the average figure for the
catarrhal variety. The leucocytes were in excess of 15,000 per
cubic millimetre in 62.5 per cent., or fifty of the counts, and
in excess of 20,000 in 25 per cent., or twenty counts, reach-
ing a maximum of 58,500 in a single instance. In 37.5 per cent.,
or thirty counts, the number of cells was below 1 5 ,000, the lowest
estimate being 6000.
In the few cases with leucocytosis in which differential counts
were made it was found that the increase was due chiefly to a
decided absolute and relative increase in the polynuclear neutro-
phils, the lymphocytes, large mononuclear forms, and eosino-
philes being relatively diminished. Neither myelocytes nor
basophilic leucocytes were observed in any of the examinations.
The following table represents the range of the leucocytes in
the 118 cases examined:
Table III. — Leucocytes.
Simple catarrhal and interstitial
Cases with abscess, gangrene, or
forms.
general peritonitis.
Leucocytes
(38 cases.)
(80 cases.)
per c. mm.
Acute.
Chronic.
0
Total.
Acute.
Chronic.
Total.
Above 50,000
0
0
1
0
1
40,000-50,000
0
0
0
0
0
0
35,000-40,000
0
0
0
2
0
2
30,000-35.000
0
0
0
0
0
0
25,000-30,000
0
0
0
3
0
3
20,000-25,000
0
0
0
14
0
14
15,000-20,000
4
0
4
30
0
30
10,000-15.000
2
9
11
19
3
22
5,000-10,000
8
9
17
7
1
8
Below 5,000
4
2
6
0
0
0
Highest,
17,100
15.000
17,100
5S,500
14,009
58,500
Lowest,
l.fiOO
2,400
l.fiOO
0,000
8,800
0,000
Average,
9,124
9,190
9,158
17,718
12,425
17.453
VALUE OF BLOOD EXAMINATIONS IN APPENDICITIS. 69
To recapitulate, an analysis of the foregoing data warants
the following conclusions :
1. The average case of appendicitis before operation shows a
loss of about 30 per cent, of hremoglobin and of more than half
a million erythrocytes per cubic millimetre. Occasionally the
anaemia is of a grade so high that it appears to constitute in itself
a serious complication and to raise a doubt as to the safety of
surgical interference, should the latter otherwise be indicated.
Doubts on this score, however, have not been justified by the
records of the cases included in this series.
2. Leucocytosis may occur both in the absence and in the
presence of an abscess and its consequences. It accompanies
about 35 per cent, of non-purulent and 90 per cent, of purulent
cases.
3. Leucocyte counts ranging between 10,000 and 15,000 or
17,000 cannot be depended upon to reflect the nature of the
local lesion, since this degree of increase may be found both in
mild catarrhal and in purulent cases. Counts of 20,000 or
more invariably indicate the presence of pus, gangrene, or
general peritonitis, one or all.
4. Leucocytosis may be absent both in trivial catarrhal
and in fulminant cases as well as in forms of circumscribed
abscess.
5. In operative cases, thorough evacuation of the abscess is
followed within a few days by a decline to normal in the num-
ber of leucocytes, provided that the recovery of the patient is
uneventful. Persistence of a leucocytosis after the third or
fourth day following the operation may usually be attributed
either to undrained pus pockets, to general peritonitis, or to
both of these factors.
Value of the Blood Changes as Diagnostic and Prog-
nostic Signs. It is obvious that a decided increase in the
number of leucocytes, if correlated with other clinical symptoms,
may serve as a diagnostic sign of definite value. On the other
hand, the fact cannot be emphasized too forcibly that an
absence of leucocytosis, except in conspicuously septic patients,
signifies nothing definite.
JO DACOSTA.
Regarding a leucocytosis of 20,000 or higher as a certain in-
dication of pus or its consequences, in my experience in one
out of every four cases of appendicular abscess the diagnosis is
justified by the behavior of the leucocytes. This may seem a
most conservative estimate of the value of the leucocyte-count
in recognizing such a condition, and its acceptance certainly
restricts the utility of the blood-count as a diagnostic aid, but
repeated observations have proved that a leucocytosis of less
than 20,000, or at the minimum 17,000, cannot be relied upon
as a trustworthy sign of pus, although, as already pointed out,
pus may exist with much lower leucocytosis.
In a patient unmistakably septic, absence of leucocytosis
should be interpreted as a sign of an intense infection, the
prognosis of which is more likely grave than favorable. A
high leucocytosis in such instances does not necessarily in-
dicate a favorable prognosis, but simply represents an intense
infection coupled with normally active resisting powers on the
part of the patient.
Absence of leucocytosis in a patient with mild indefinite
symptoms is a clinical sign of no tangible value in so far as it
may serve in detecting the presence of pus, since a large
abscess if thoroughly circumscribed may exist without causing
the slightest increase in the number of leucocytes.
In cases treated surgically the adoption of daily leucocyte
counting as a routine procedure during the first week after the
operation furnishes the surgeon with definite information re-
garding the progress of the case, since the advent of complica-
tions or the failure to secure complete evacuation of pus foci
may be detected by the persistence of or an increase in the
leucocytosis.
Unfortunately, it happens that just those conditions which
bear the closest resemblance to appendicitis as a rule give rise
to blood changes identical with those found in the latter dis-
ease, so that the value of the blood-count as a means of differ-
ential diagnosis is greatly limited. Thus, leucocytosis is the
rule in such conditions as oiiarian abscess, pyosalpinx^ ectopic
pregnancy, perinephritic abscess, hepatic abscess, empyema of the
VALUE OF BLOOD EXAMINATIONS IN APPENDICITIS. 7I
gallbladder, and malignant disease of the ccBcuni, all of which
have been confused with appendicitis. Such a large proportion
oi renal and hepatic colics are associated with inflammatory com-
plications that neither of these conditions can be distinguished
with any degree of confidence from appendicitis simply by the
examination of the blood. Acute gastritis is sometimes accom-
panied by a well-marked leucocytosis, and sometimes by none
at all, so that the blood-count cannot be relied upon as a clue
in distinguishing this disease from appendicitis. The same is
true of dysmeiiorrhoea, in which disease uterine inflammatory
changes may be the factor of a leucocyte increase. Should the
diagnosis lie between appendicitis and enteric fever the former
is suggested by the presence of a leucocytosis, since this sign
practically never occurs in typhoid, except in the event of some
obvious complication, such as hemorrhage from the bowel or
perforation.
In doubtful cases a leucocytosis is sufficient to exclude such
non-inflammatory lesions as simple enteralgia, lead colic, ovarian
neuralgia, an ovarian cyst, and a movable kidney.
THE BLOOD CHANGES INDUCED BY THE ADMIN-
ISTRATION OF ETHER AS AN ANESTHETIC.
By JOHN CHALMERS Da COSTA, M.D.,
AND
FREDERICK J. KALTEYER, M.D.,
PHILADELPHIA.
(y4 Contribiition from the Laboratories of the Jefferson Medical College Hospital.')
Many years ago it was asserted that the administration of an
ansesthetic has a destructive influence upon the blood. This
view was a mere opinion, and was not deduced from well-
conceived and carefully performed experiments.
Dr. John Snow believed and taught that an anaesthetic agent
suspends the processes of oxidation, and that the essence of the
anaesthetic state is suspended oxidation. This view has been
advocated in modern times by Richardson, but has of late been
entirely overthrown by a recognition of the facts, stated by
Buxton, that we can produce anaesthesia by hyperoxidation,
and that a number of " deoxidizing bodies " are not anaesthetics.
In i86i Sansom made a report to the Royal Medico-Chirurgi-
cal Society, in which he maintained that during anaesthesia
quantities of blood-corpuscles are destroyed. He did not ex-
amine the blood before, during, and after anttsthesia, but made
experiments upon blood in test-tubes by adding to it anaesthetic
drugs. He found that the addition of an anaesthetic to blood
outside of the body destroys the corpuscles and liberates color-
ing matter. The above method was, of course, inconclusive,
could give no positive information, and was, at most, merely
suggestive.
BLOOD CHANGES INDUCED BY ETHER. 73
In 1869 Dr. J. H. McQuillen' made a series of experiments
in order to determine the condition of the corpuscles of the
blood during the an;usthetic state. He examined the blood of
a number of human beings prior to and after the administration
of ether, chloroform, and nitrous oxide, and stated that he found
no evidence of corpuscular destruction.
In 1890 Mikulicz^ presented the studies of a pupil, Bierfreund,
in regard to the amount of haemoglobin in the blood in surgical
diseases, with special reference to its restoration after the oc-
currence of hemorrhage. He was the first to observe that the
administration of chloroform may reduce the haemoglobin from
5 to 10 per cent.
In 1893 Garrett and Oliver,'^ performed numerous experiments
and arrived at the conclusion that anaesthetics, particularly
chloroform., deoxidize the blood and also the tissues, and thus
induce malnutrition and the formation of quantities of waste
products, the elimination of these toxic products causing a
severe and possibly dangerous, or even a fatal, strain upon the
excretory glands. Garrett and Oliver also pointed out the fact
that a patient under the influence of ether sweats profusely, a
process which lowers the temperature, the temperature being
also lowered by the evaporation of ether and by depression of
the nervous system.
In this paper we point out that the sweating which occurs
under ether must be taken into consideration in estimating
blood changes.
In 1895 one of us (J. Chalmers Da Costa) made an investiga-
tion of the action of ether upon the blood, he being at that time
unaware of Mikulicz's observations upon chloroform or of any
other studies of a like sort. The experiments were published in
the Medical Nlivs of March 2, 1895. The blood was examined
before, during, and after etherization. Twenty-seven cases were
studied. In the majority there was a distinct fall of haemo-
globin. It was also observed that the red corpuscles were often
' Dental Cosmos, March, 1869.
■-' Beilage z. Centralbl. f. Chir., 1890, No. 25. ' Lancet, September 9, 1893.
74 DA COSTA AND KALTEYER,
altered in shape, but that they were not diminished in number.
The diminution in the amount of haemoglobin was found to be
most marked in anaemic individuals — an observation which
seems to afford an explanation of the reason why operative
shock is usually so profound and prolonged in the anaemic. In
Da Costa's cases the counts were made by means of a Thoma-
Zeiss haemocytometer, and the haemoglobin was estimated by
the instruments of Gowers and Fleischl. That the fall in haemo-
globin was not entirely due to hemorrhage was indicated by
the fact that it occurred in some bloodless cases ; for instance,
an examination of a strictured rectum, the reduction by taxis of
an inguinal hernia, and the breaking up of adhesions in an
ankylosed metacarpo-phalangeal joint. It was also noted that
ether given as an anaesthetic markedly lowers the temperature.
This fall of temperature begins with the anodyne stage, and
averages from i° to 3° F., but may reach 4° or even 5° F.
That the fall is not due purely to shock is proved by its occur-
rence in trivial operations and by the rapid ascent of the tem-
perature on suspending the administration of the anaesthetic.
Among the conclusions deduced from these experiments were
the following :
"Etherization produces a marked diminution in the hitmo-
globin of the blood.
"The red corpuscles and the h^tmoglobin are especially
affected in blood previously diseased.
" Irregular records are due to faulty observation, to the
presence of altered hemoglobin in the blood, to the faulty
aberration as to the color of a Fleischl instrument, or to taking
blood before anaesthesia is complete.
" The white corpuscles show irregular changes which are not
characteristic, and exhibit variations not more pronounced
than would be found in the same number of samples of normal
blood on different examinations.
"Age does not apparently influence the results.
"The often quoted observation as to the effect upon the
haemoglobin of shock and hemorrhage requires enlarged repeti-
tion upon human beings before the statements that hemorrhage
BLOOD CHANGES INDUCED BY ETHER. 75
causes a great fall in the amount of haemoglobin, but that shock
does not affect it, can.be accepted.
" Prolonged anaesthesia profoundly deteriorates the blood
and strongly militates against recovery ; hence, rapidity of
operation is most desirable."
One or two other conclusions which do not seem to bear upon
our present study are not cited.
The above quoted studies, if correct, indicate that the blood
of a patient should be examined before an anaesthetic is ad-
ministered, and that if marked anaemia exists, or if the amount
of hitmoglobin is lowered, the administration of an ant-esthetic
must be regarded with apprehension. If it is found necessary
to employ one. it must be administered by a skilled anresthetist.
As little as possible should be given ; oxygen should be admin-
istered with it; the surgeon should work' rapidly ; the patient
should be carefully protected from cold, and vigorous efforts to
bring about reaction should be promptly made as soon as the
operation is complete, or even during its performance. If the
amount of haemoglobin is very low, no general anaesthetic
should be given.
Da Costa made no attempt to obtain information as to the
lowest amount of haemoglobin which is consistent with the
fairly safe administration of an anaesthetic. Mikulicz estimates
it at 30 per cent, for chloroform. He believes that the admin-
istration of chloroform when the haemoglobin is only 20 per
cent, will be followed by respiratory paralysis. In three
patients who died of operative collapse, Mikulicz found but 15
per cent, of haemoglobin remaining in the blood.
These views in regard to the deteriorative influence of ether
upon the blood have been accepted by some and rejected by
others. It has generally been accepted that ether causes leu-
cocytosis which is probably of a toxic character, but its action
upon the red corpuscles and haemoglobin is still a matter of
dispute. Von Lerber' reports a study of the blood in lOi
cases after the inhalation of ether. He asserts that in most in-
1 Centr,)lbl. f. Gyniikologie. 1897, No. 19.
76 DA COSTA AND KALTEYER,
stances the haemoglobin was unaltered. He found leucocytosis,
but the red corpuscles were very little changed, either in num-
ber or in appearance. He made a spectroscopic study of the
urine, but as he was unable to find urobilin, he concluded that
ether does not exert any harmful influence upon the blood and
does not set free ha.'moglobin. The belief that because urobi-
lin is not discovered in the urine none is set free in the blood
is, to our mind, not warranted by conclusive observations.
Von Lerber, however, points out that the more prolonged the
anaesthesia the more marked is the leucocytosis.
Oliver' says that observations should be made upon animals
in order to determine whether normal red corpuscles are affected
by ether. He believes that observations made before, during,
and after operations are entirely unreliable, because the opera-
tion, whether or not it is accompanied by bleeding, disturbs the
composition of the blood. Oliver made a number of observa-
tions upon rabbits, keeping each animal under the influence of
the aniiisthetic one hour. He found the average blood decimal
to be I.I before anaesthesia, and 0.98 after anaesthesia ; during
anaesthesia the corpuscles appeared to be normal, and there
were apparently no injurious after-effects. He says that this
indicates that ether does not affect normal red corpuscles, but
he admits that it may affect those that are diseased, and he is
quite sure that the resisting power of the stroma of the cor-
puscles must vary under the influence of ether.
Dudley W. Buxton" says : " In every case, blood removed
from the body and shaken with an anaesthetic shows destruction
of the corpuscles and reduction with pouring out of haemo-
globin ; and it would also appear that a similar if less marked
phenomenon occurs in the body." Because of some observa-
tions he has made, Buxton has become persuaded that there is
a decided diminution in hremoglobin when an animal is under
the influence of ether, chloroform, or nitrous oxide. He says:
" It is, however, not improbable that factors other than the an-
jiesthetics may be found at work in bringing about this result.
' Lancet, June 27, 1896. '^ Ibid., February i. 1896.
BLOOD CHANGES INDUCED BY ETHER. y/
The combination or association between the gaseous anaes-
thetics, or vapors, and the constituents of the blood must be a
U^ose one, since in their presence oxygen is displaced. Were
they to form combinations as stable as that which carbonic
oxide establishes, not only would the an;Lsthetic displace the
oxygen, but it would render impossible the re-formation of
oxyhasmoglobin ; hence, death must result." Buxton goes on
to state that it is impossible to say whether the corpuscles, in
some cases after the administration of an anaesthetic, have a
lessened power of taking up oxygen, but that it seems probable
that such is the case.
Hamilton Fish^ has contributed an extremely valuable article,
which he designates "The Importance of Blood Examinations
in Reference to General Anaesthetization and Operative Pro-
cedures." He takes the affirmative on the' question of whether
or not ether reduces haemoglobin and affects red corpuscles.
He believes that ana:;sthetics may lessen tissue resistance, and
thus lead to septic lesions; and he thinks that the condition of
the blood is a fairly accurate gauge of the patient's general con-
dition, and that the blood should always be examined before
the administration of an anaesthetic. He says that those who
labor under neurasthenia, anaemia, chlorosis, leukemia, and
the lymphatic temperament have blood in which marked
changes can be demonstrated ; and that all of these patients
stand operation and also anaesthesia badly. Fish advocates
the belief that an anaesthetic extracts oxygen from oxyhaemo-
globin, and combines with the latter; and he further asserts
that in patients with less than 50 per cent, of hiumoglobin
oxygen is taken away from corpuscles which are so poor in
that element that they cannot spare it. As a consequence,
such corpuscles are unable to give up any oxygen to the tissues,
and these patients, when under the influence of ether, will show
evidence of collapse. Fish reminds us that respiration depends
upon the nervous system and upon the amount of h^iimoglobin
in the blood, and that if h.tmoglobin is reduced below a certain
' Annals of Surgery, July, 1899.
jS DA COSTA AND KALTEYEK,
limit respiration will cease. He thinks that the minimum is
20 per cent., and refers to the observations of Mikulicz, that in
three cases dying of collapse during operation, 15 per cent, of
hitnioglobin was found remaining in the blood. In Fish's
opinion, the safest rule is not to give an anaesthetic if the
hfemoglobin is under 50 per cent. ; anything above 80 per cent,
he considers normal. An amount of anesthetic which is per-
fectly harmless when there is 80 per cent, of haemoglobin may
be extremely dangerous when there is but 50 per cent. Fish
also points out the important fact that safe anctsthesia depends
not alone upon a good percentage of haemoglobin, but also
upon the existence of a normal or increased number of poly-
nuclear neutrophils. He regards the leucocytosis of anaes-
thesia as phagocytic in character, and as a measure of individual
resistance. He believes that the blood should be examined not
only before but during anaf;sthesia, because the first evidence of
approaching danger may be found in a blood change. He also
points out the interesting fact that at an altitude of one mile
normal haemoglobin is reduced from 12 to 15 percent during
the first hour of anaesthesia.
Dr. Joseph C. Bloodgood,' of the Johns Hopkins Hospital,
in reviewing Dr. Hamilton Fish's article, entirely agrees with
that author's conclusions, and cites several cases occurring in
the Johns Hopkins Hospital to confirm these views.
From the above quoted opinions it will be observed that
wide divergences exist among the views of the different writers
upon this subject — between the views which J. Chalmers
Da Costa put forth in 1895 and the results of the experiments
upon rabbits made by Oliver ; between the broad affirmation of
the belief that ether lowers haemoglobin and has a destructive
influence upon corpuscles, in the article by Hamilton Fish, the
absolute denial of this by Von Lerber, and the rather conservative
opinion of Dudley Buxton. The controversialists are as the two
knights of allegory who stood upon opposite sides of the shield
disputing as to the words graven upon it. Each saw his own
side, and each was right and each was wrong. It becomes
' Progressive Medicine, 1900, vol. iv.
BLOOD CHANGES INDUCED BV ETHEK. 79
evident that some of the observations must be entirely errone-
ous, or else undiscovered factors and unrecognized elements ex-
ist in the problem which make all previous observations never
entirely correct and never completely wrong. These discrep-
ancies and disagreements may depend upon the personal incre-
ment, upon the employment of different methods to estimate
the h;\.'moglobin, upon the different altitudes above the sea at
which the experiments were made; upon the daily and nightly
oscillations which are known to occur in the percentage of
haemoglobin and corpuscles ; upon the uncertain results obtained
by the h.tmoglobinometer ; upon the different methods taken
to secure the blood, and the fact that it may have been taken
from different portions of the body; upon the fact that the ex-
tremity from which the blood was taken may or may not have
been elevated, and also that massage and manipulation may or
may not have been employed; because in some cases digestion
may have been going on, and in others it may not have been ;
and particularly upon the fact that in some cases the blood
may have been concentrated by purgation and diaphoresis, and
in others it may not have been so concentrated.
In Da Costa's former cases the patients in many instances
were taken from the dispensary and etherized without pre-
vious preparation. In this new series of cases we determined
that the patients should be carefully prepared for operation — a
preparation which involves concentration of the blood by pur-
gation, which concentration is usually added to by profuse per-
spiration during the anaesthetic state. We further determined to
have all the blood examinations made by a thoroughly com-
petent third party, who was to make them all in exactly the
same manner, and was to have no preconceived views, and who,
in consequence, would not be lured from the path of accurate
observation by any theoretical jack-o'-lantern. We selected for
this work Dr. A. G. Ellis, the Pathological Resident of the
Jefferson College Hospital, who performed it with the utmost
skill and care ; and we wish here to extend to him our thanks.
Further, we decided that the table when completed should be
broken up into numerous subtables, according to the time before
80 DA COSTA AND KALTEYER,
and after operation the blood was examined, to the duration of
the anaesthesia, to the amount of ether used, to the estimated
quantity of blood lost, etc.
It is our aim in these investigations to consider the subject
as far as possible from a practical stand-point rather than from
an experimental view-point. We concluded to gather fifty cases,
taken out of the general run of patients in a busy hospital — the
Jefferson Medical College Hospital. The cases were selected
from the various wards, surgical, gynecological, etc. The blood
examinations, which were made before and after the operations,
consisted of the estimation of the number of erythrocytes, the
haemoglobin percentage, the color index, and the number of
leucocytes. Differential counts of the leucocytes were not
undertaken, for it was not our object to study the leucocytic
changes in detail. The results of the blood examination before
the operation were compared with those after the operation. It
was practically impossible to always set a definite time before
the operation as the period in which the observation should be
made, so we decided to make the examination in a number of
cases within a reasonable period preceding the operation — that
is, within some hours of the time of going to the operating-
room. In other instances the blood examinations were made
some time before going to the clinic-room, on account of post-
ponement of the operation. In some cases examination was
deliberately made a considerable time before operation in order
to anticipate preparatory methods of treatment. Similar diffi-
culties were encountered in arriving at the proper time for the
blood examinations after the operation. The counts following
the operation were made either immediately after or upon the
day following. Examinations were not made during the anaes-
thetic state, for our particular aim was to determine the changes
which follow etherization rather than the changes that are noted
during the anaesthetic period.
Blood Concentration.
The problem of blood concentration naturally presented
itself, because the preparatory treatment includes measures
BLOOD CHANGES INDUCED BY ETHER. 01
which tend to increase the elimination of the watery principles
of the body, while the intake of fluids is always reduced prior
to and for a time after the operation.
The general rules gov Qvn'xrvg preparatory measures of treatment
at the Jefferson Medical College Hospital consist of
{a) A hot bath.
(d) Active purgation.
(c) Reduction of diet and withholding of all food and liquid
for some hours preceding the operation.
(d) Occasionally, though rarely, the administration of heart
stimulants.
Cause of Blood Concentration.
It is generally admitted that such conditions as increased
blood-pressure, diarrhcea, profuse sweating,' constant vomiting,
the v/ithdrawal of a large quantity of serous fluid, which is
rapidly replaced by the transfusible elements of the blood, and
deprivation of fluids — all tend to produce blood inspissation.
It is a well-known fact that the blood of individuals suffering
from Asiatic cholera shows concentration to a high degree.
The finding of 6,000,000 or more red blood-cells per cubic milli-
metre in this disease is not unusual. Cabot/ in referring to the
work of Hay On the Action of Saline Cathartics^ states that
" Hay gives the following figures showing the effect of sulphate
of sodium in concentrating the blood : Subject, a healthy man,
aged thirty-three years ; 3.35 p.m., red corpuscles, 5,250,000; was
given 85 c.c. of a concentrated solution of sulphate of sodium in
water. Thirty-five minutes later the blood-count showed red
corpuscles, 6,540,000; sixty-five minutes later the blood-count
showed red corpuscles, 6,790,090 ; four hours later the blood-
count showed red corpuscles, 4,930,000. Evidently much fluid
was drawn out of the bloodvessels, and then within four hours
the tissues had supplied the loss, and the blood had returned
to its normal density. Hay also showed that a dilute solution
of the same drug had far less effect in concentrating the blood.
1 Clinical Examination of the Blood.
Am Surg 6
82 DA COSTA AND KALTEYER,
Further, he demonstrated that if blood is already concentrated
when the saline is given no purgative effect follows."
Concentration is well shown after profuse sweating. Oliver^
reports temporary apoplasia produced by a Turkish bath. In
this case the corpuscular percentage was 91 before the bath,
while immediately after the bath it was 106, and two hours after
the bath the percentage fell to almost 99. Thirty ounces of
beer were ingested half an hour after the bath.
Oliver,' in referring to the variations in the volume of the
plasma, states that : " When, for example, the output of water,
whether by the kidneys, the skin, or the bowels, temporarily
exceeds the income, the volume of the plasma is for a time re-
duced, and there is a proportionate rise in the corpuscles." He
further states that " the concurre?it variations in the percentage
of the corpuscles and haemoglobin, which have been so repeat-
edly pointed out, are indeed volumetric indications of the circu-
lation of the water into or from the blood — into it from the
digestive tract and the tissues, and from it by the kidneys,
skin, and lungs, and probably into the muscles during exercise.
The blood is continually tending to balance its income and out-
put of water, and is thus always striving for a mean ; but not-
withstanding this wonderful persistent adjustment, variations in
the proportion of water present in the plasma are at the same
time shown by these observations to be constantly taking place
within certain physiological limits."
Blood inspissation is also produced by increased blood-pres-
sure. For example, small doses of suprarenal extract increase
arterial tension, and hence favor elimination of water and induce
polycythremia. It is worthy of mention that in the blood con-
centration occurring in the healthy individual within physiologi-
cal limits the rise in the corpuscular and h^vmoglobin percentage
is parallel. The blood decimal, therefore, does not change. The
rapidity with which the blood loses some of its diffusible ele-
ments, therefore, must always be borne in mind, and the quick-
ness with which the blood is again diluted is a matter no less
I Lancet, June 27, 1896. '^ Ibid.
BLOOD CHANGES INDUCED BY ETHER. 83
important. It is undoubtedly true that the loss of the watery-
elements of the plasma is only transitory, nevertheless the
rapidity with which the blood tends to reach the normal proba-
bly varies greatly in individual cases, and is modified by many
factors. The following statement of Cabot' in regard to the
subject of blood concentration is indeed worthy of careful con-
sideration at all times when dealing with blood examinations.
" In the presence, therefore, of any such reason for the con-
centration of the blood, we should always modify our ordinary
methods of inference from the blood-counts."
Blood Destruction [Hcemolysis) and Blood Formation [HcBmo-
genesis).
In health the number of erythrocytes and the amount of
haemoglobin maintain a uniform standard — ;the formation of the
new red blood-cells and the destruction of the colored elements
progress uniformly. The subject regarding the average life
of the erythrocytes has received much discussion, but still
remains an unsettled question. It has been suggested that the
average duration of life of the chromocyte appears to be about
two weeks or less. Therefore, 357,152 red blood-cells per cubic
millimetre are destroyed each day — in other words, the destruc-
tion is at the rate of 248— per minute in each cubic millimetre
of blood. Haemogenesis progresses accordingly.
Blood Regeneration.
It is essential, in order to base our conclusions upon scientific
principles, to consider the generally accepted views governing
blood regeneration. These may be summarized as follows :
Immediately following a loss of blood, for example, a trau-
matic hemorrhage, the erythrocytes and the haemoglobin are
reduced proportionately ; in a short time the other tissues of the
body compensate for the volume of fluid lost from the blood.
Following this dilution, erythrocytic regeneration progresses
rapidly, and the number of corpuscles lost is restored to the
1 Clinical E.xamination of the Blood,
84 DA COSTA AND KALTEYER,
proper level in a short time; the haemoglobin, however, is not
replaced so quickly. Therefore, the newly formed corpuscles
in the circulation are deficient in coloring-matter, and the total
haemoglobin percentage is below the corpuscular percentage,
consequently there is a reduction in the average blood decimal.
After the lapse of some time the haemoglobin is restored and
the erythrocytic regenerative properties of the blood-making
organs gradually become normal.
Blood Concentration and Ancemia.
Blood concentration may progress or be associated with
anaemic states. In cases of this kind the total volume of blood
is reduced, the number of erythrocytes may appear to be nor-
mal or exceed the normal, while the haemoglobin will not pre-
sent the same increase, although the percentage may be increased,
but the total amount is diminished, as is shown by the lowered
color index. When the blood becomes diluted and inspissation
disappears the percentage of corpuscles and haemoglobin is
lowered, while the blood decimal remains unaltered unless im-
provement follows, which will be indicated by a rise in the
corpuscular haemoglobin value.
Records.
In gathering our clinical data we particularly emphasize the
points bearing upon the conditions which produce blood inspis-
sation, endeavoring to determine, therefore, in a general way,
the loss of the watery constituents of the body. The task of
gathering the clinical notes was assigned to the resident physi-
cians of the Jefferson College Hospital. The following chart
was prepared so as to facilitate their work :
Number. Name. Age. Sex. Date.
Nativity. Occupation. Ward. Physician.
Diagnosis. Date of admission.
Date of discharge.
Revised diagnosis. Result.
History.
Physical examination.
Character and amount of urine in twenty-four hours before and after anaesthesia.
BLOOD CHANGES INDUCED BY ETHER. 85
Character and amount of vomit before and after anaesthesia.
Character and amount of bowel movement before and after ansesthesia.
Amount of sweating before and after anaesthesia.
Remarks. (Was any large quantity of fluid lost before or after operation?)
Date. Hour, and character of operation.
Blood loss.
Duration of anaesthesia.
Character and amount of anassthetic.
Blood Examinations.
Date and hour before operation. Date and hour after operation.
Haemoglobin. Haemoglobin.
Erythrocytes. Erythrocytes.
Leucocytes, Leucocytes.
Color index. Color inde.v.
HcBmatological Methods.
In procuring the blood for examination the following rules
were always observed. The patients were in the recumbent
posture; the blood was taken from the tip of the finger. In no
case was the hand oedematous. The skin was cleansed with
water or a little soap and water ; next with alcohol, and was
then dried. The part was warmed by a gentle friction. Care
was taken not to excite active hyperaemia by vigorous rubbing.
The puncture was effected with a clean needle having a cutting
surface, and was made deep enough to insure a free flow of blood
without squeezing the part near the wound. The first drop was
always wiped away. The number of erythrocytes and leuco-
cytes was estimated with the Thoma-Zeiss hcEmocytometer.
In determining the number of the red cells a 2 per cent, salt
solution was used as a diluent in the proportion of one part of
blood to 20C> parts of the solution. A i per cent, acetic acid
solution was used as the diluting fluid in the proportion of i to
20 in estimating the number of leucocytes. In ascertaining the
number of erythrocytes the corpuscles in 80 squares were
counted, while the corpuscles in 400 squares were enumerated
in determining the number of leucocytes. The haemoglobin
86
DA COSTA AND KALTEYER,
estimations were made with Oliver's haemoglobinometer, except
in 4 cases, in which the Fleischl instrument was employed.
Table I.
Before ansesthesia.
After anaesthesia.
DiflFerence.
Color
Hsemo.
Haemo.
Color loss. loss.
index
No.
Corpus-
Color
Hsemo.
Corpus-
Color
loss.
Color
index
gain.
cles.
index.
perct.
cles.
index.
per ct.
60
Color gain.
Hsemo.
gain.
1
3,245,000
0.89
58
3,920,000
0.76
675,000-1-
2+
0.13
2
4.170,000
0.9
75
5,390,000
0.742
80
1,220,000+
5+
0.158
3
3,795,000
0.724
55
4,330.000
0.577
50
535,000-1-
5—
0.147
4
4,050,000
0.92
75
5,160.000
0.82
85
1,110,0004-
10+
0.10
5
5,340,000
0.889
95
5,370,000
0.884
95
30,000-1-
0+ 0—
0.005
6
5,130,000
0.926
95
5,250,000
0.9
95
120,000 +
0+ 0—
0.026
7
4,575,000
0.82
75
4,600,000
0.76
70
25,000 +
5—
0.06
8
4,680,000
0.908
85
4,850,000
0. H24
80
170,000 +
5 —
0.084
9
4,750,000
0.863
82
4,620,000
0.811
75
130.000—
7 —
0.052
10
4,520,000
0.94
85
4,950,000
0.808
80
430.000 +
5-
0.132
11
4,500,000
0.944
85
4,240,000
0.943
80
260;000-
5—
0.001
12
4,375,000
0.857
75
4,387,000
0.683
60
12,500+
15—
0.174
13
3,820,000
0.982
75
4,810,000
0.779
75
990,000+
0+ 0—
0.203
14
5,660.000
0.75
85
5,490,000
0.728
80
170,000-
5—
0. 022
15
5,210,000
0.959
100
5,360,000
0.886
92
150.000+
5—
0.073
16
3,680,000
0.87
64
5,230,000
0.592
62
1,550,000+
2—
0.278
17
4,160,000
0.S41
70
3,900,000
0.77
60
260,000—
10-
0.071
18
4,940,000
0. 88
87
5,600,000
0.848
9§
660,000+
8 +
0.032
19
5,140,000
0. 826
85
4,850,000
0.824
80
290,000—
.5—
0.002
20
4,710,000
0.934
88
5,925.000
0.798
95
1,215,000 +
7 +
0.136
21
5,560,000
0.809
90
5,800,000
0.801
93
240,000+
3+
0.008
22
5,190,000
0.915
95
5,880,000
0.85
100
690,000+
5+
0.065
23
4,920,000
0.945
93
5,740,000
0.827
95
820.000+
2+
0.118
24
3,970.000
1.000
80
3,890,000
0.964
75
80.000—
5-
0.036
25
4,440,000
0.822
73
5,650,000
0.796
90
1,210.000+
17 +
0.026
26
4,780,000
0.868
83
4,870,000
0.739
72
90.000+
11—
0.129
27
4,820,000
0.964
83
5,137,000
0.924
95
317,000 +
12—
0.040
28
5,430,000
0.874
95
6,130,000
0.792
loo
700,000+
5+
0.082
29
5,650,000
0.911
103
6,070,000
0.807
98
420,000 +
5—
0.104
30
5,070,000
0.936
95
6,375,000
0.902
115
1,305,000+
20+
0.034
31
4,880,000
0. 922
90
5,360,000
0.904
97
480,000+
7 +
0.018
32
5,480,000
0.865
95
6,620,000
0.83
110
1,140,000+
15+
0.035
33
5.520,000
0.995
110
6,120,000
0.776
95
600,000+
15—
0.219
34
5,160,000
0.92
95
6,090,000
0.862
105
930.000 +
10 +
0.058
35
5,040,000
0.992
100
5,720,000
0.83
95
680,000 +
5—
0.162
36
5,590,000
0.983
110
6,225,000
0.963
120
635,000 +
10+
0.020
37
5,890,000
0. 933
110
6.710,000
0.842
113
820.000+
3 +
0.091
38
6,130,000
0.938
115
5,380,000
0.93
100
750,000—
15—
0.008
39
3,900,000
0.641
50
4,060,000
0.492
40
160,000+
10-
0.149
40
6,280,000
0.954
120
6,070,000
0.98
113
210,000-
7
0.024
41
6,100,000
0.983
120
6,170,000
0. 988
122
70,000*
2+
0. +
42
4,920,000
0.873
80
5,300,000
0.66
70
380,000+
10-
0.213
43
5,550,000
1.030
115
6,030,000
0.829
100
480,000 +
15—
0.201
44
4,600,000
1.000
92
5,050.000
0.891
90
450,000+
2—
0.109
45
5,350,000
0.981
105
4,880,000
0.922
90
470,000-
15—
0.059
46
4,880,000
1.020
100
6.040,000
0.91
110
1,160,000+
10 +
0.11
47
5,330,000
0.863
92
5,750,000
0.782
90
420,000+
2—
0.081
48
4,700,0fi0
0.957
90
5.120,000
0.859
88
420,000 +
2—
0.098
49
5,500,000
0.936
103
5,700,000
0.831
95
200,000 +
8—
0.105
50
5,940,000
0.942
112
89
6,080,000
0.904
110
86-1-
1,140,000 +
149,360+
2—
■
0.038
Aver.
4,977,440
0.9C3
5,126,800
0.821
»-
0.082
BLOOD CHANGES INDUCED BY ETHER. 8/
Tabulation of Cases.
After the various facts had been collected the 50 cases were
arranged in tabular form. The facts included in this table are
the name, sex, nativity, and occupation of the patient, the ward,
diagnosis, the date of admission, the date of discharge, the result,
the character of the operation, the date and hour of operation,
the estimated blood loss, the anaesthetic employed, the amount
of the anaesthetic used, the duration of the period of anresthesia,
the date and hour of the blood examination before the opera-
tion. The examination includes the haemoglobin percentage,
the number of erythrocytes per cubic millimetre, the number of
leucocytes per cubic millimetre, and the color index. The date
and hour of the blood examination after the operation, which
again includes the haemoglobin percentage, the number of ery-
throcytes per cubic millimetre, the number of leucocytes per
cubic millimetre, and the color index.
General Summary of the Blood Changes.
Erythrocytes. The number of chromocytes was increased in
41 cases and decreased in 9. The average count before the
operation was 4,977,440. The average count following the
operation was 5,126,800, and the gain was 143,360 per cubic
millimetre.
Hcsmoglobin. The average haemoglobin percentage preced-
ing the anaesthetic state was 89. The average haemoglobin per-
centage following the anaesthetic state was 86, showing a loss of
3 per cent. The haemoglobin revealed an increase in 19 cases
and a decrease in 28 cases, and there was no loss or gain in
three instances. The average gain in the 19 cases was 8.05 per
cent., while the average loss in the 28 cases was 7,25 per cent.
Color Index. The average individual corpuscular haemoglobin
value preceding the operation was 0.903 , while that following was
0.821, showing an average loss of 0.082. In 49 out of 50 cases
the blood decimal was reduced after the operation. In one
instance only was the color index slightly increased after the
anx'sthetic state. This occurred in case No. 41, the color index
DA COSTA AND KALTEYER.
preceding the operation was 0.983, and that following the opera-
tion was 0.988. In this instance the blood decimal was practi-
cally unchanged.
Table II. — Group A.
Blood examinations made a short time before and soon after anaesthesia.
Time between bloocl-couut
Time between operation
X umber.
before operation and
and blood-count after
operation.
operation.
6
3 hours 15 minutes.
6 hours.
7
2 "
5 '
8
3 "
5 '
9
2 "
4 '
45 minutes.
10
2 " 15 minutes.
4 '
30
13
1 hour 30 "
2 '
18
3 hours.
5 '
.30 minutes.
29
3 ' ' 30 minutes.
6 '
36
2 "
4 '
37
1 hour 30 minutes.
5 '
30 minutes.
40
2 hours 30 "
6 '
41
1 hour 30 "
3 '
44
2 hours 30 "
4 '
45
1 hour 45 "
4 "
30 minutes.
49
3 hours.
4 '
30 "
Average 2 hour
s 21 minutes. Avera
ge 4 hours 41 minutes.
Group B.
d examinations
made a short time before and
some time after ansesthe
Time between blood-count
Time between operation
Number.
before operation and
and blood-count after
operation.
operation.
11
2 hours 45 minutes.
17 hours 30 minutes.
12
1 hour.
21 '
45 "
14
2 hours.
22 '
19
1 hour 30 minutes.
21 '
45 minutes.
22
2 hours 15 "
21 '
23
2 " 45 "
20 '
' 30 minutes.
2.5
5 " 30 "
22 '
30 "
26
1 hour .'JO "
24 '
27
4 hours.
21 '
30 ''
28
3 •' 30 minutes.
17 '
30
4 "
19 '
32
3 " 30 minute.s.
19 '
' 30 minutes.
33
2 "
21 '
30 "
34
1 hour 30 minutes.
22 '
3.5
. 3 hours 30 "
19 '
38
. 3 " 15 "
21 '
42
. 3 "
21 '
43
3 " 30 minutes.
21 '
' 45 minutes.
46
0 " 45 "
23 '
47
. 3 " 45 "
20 '
' 30 minutes.
48
2 "
22 '
50
2 " 15 minutes.
22 '
Average 2 hours 51 minutes.
Average 20 hours 59 minutes.
BLOOD CHANGES INDUCED BY ETHER.
89
Group C.
Blood examinations made some time before and soon after anaesthesia.
Number.
16
21
Time between blood-count
before operation and
operation.
19 hours 00 minutes.
23 "
16 •'
Time between operation
and blood-count after
operation.
4 hours 5 minutes.
1 hour.
7 hours 45 minutes.
Average 19 hours 38 minutes.
Average 4 hours 16 minutes.
Group D.
od examinations made
some time before
and
some
time after antesthes
Time between blood-count
Time between operation
Number.
before operation and
and blood-count after
operation.
operation.
1
. 23 hours 10 minutes
19 h
ours 5 minutes
2
. 29
23 "
19.
7 "
3
.. 25
10 "
20
50 "
4
. 69
30 "
18
15
. 72
19
17
. 23
21
30 minutes.
20
. 24
30 minutes.
22
30 "
24
. 19
19
30 "
31
. 98
30 minutes.
21
39
. 26
20
Average 41 hours 1 minute.
Average 20 hours 3 minutes.
Table III.— Group (a).
First count made
Second count made
Corpuscle gain or loss.
Col. index
a short time
soon after
,
■
gain or
before ansesthesia.
anfesthesla.
Gain.
Loss.
loss.
6
5,130,000
5,250,000
120,000
0.026
7
4,575,000
4,600,000
25,000
0,06
8
4,680,000
4,850,000
170,000
0.084
9
4,750,000
4,620,000
130,000
0.052
10
4,520,000
4,950,000
430,000
0.132
13
3,820,000
4,810,000
990,000
0.203
18
4,940,000
5,600,000
660,000
0.032
29
5,650,000
6,070,000
420,000
0.104
36
5,590,000
6,225,000
635,000
0.02
37
5,890,000
6,710,000
820,000
0.091
40
6.280,000
6,070,000
210,000
0.024
41
6,100,000
6,170,000
70,000
+slight
44
4,600,000
5,050,000
450,000
0.09
45
5,350,000
4,880,000
470,000
0.059
49
5,500,000
5,700,000
200,000
0.105
Aver, gain 265,000 Aver, loss 0.077
90
DA COSTA AND KALTEYER,
Group (b).
First count made
a short time
lefore anaesthesia.
Second count made
Corpuscle
gain or lo.ss.
Col. index
gain or
loss.
h
avjiiic Liiiic aiici
anaesthesia.
Gain.
Loss.
11
4,500,000
4,240,000
260,000
0.001
12
4,375,000
4,387,500
12,500
0.174
14
5,660,000
5,490,000
170,000
0.022
19
5,140,000
4,850,000
290,000
0.002
22
5,190,000
5,880,000
690,000
0.065
23
4,920,000 '
5,740,000
820,000
0.118
25
4,440,000
5,650,000
1,210,000
• 0.026
26
4,780,000
4,870,000
90,000
0.129
27
4,820,000
5,137,000
317,000
0.040
28
5,430,000
6,130,000
700,000
0.082
30
5,070,000
6,375,000
1,305,000
0.034
32
5,480,000
6,620,000
1,140,000
0.035
33
5,520,000
6,120.000
600,000
0.219
34
5,160,000
6,090,000
930,000
0.058
35
5,040,000
5,720,000
680,000
0.162
38
6,130,000
5,380.000
750,000
0.008
42
4,920,000
5,300.000
380,000
0.213
43
5,550,000
6,030,000
480,000
0.211
46
4,880,000
6,040,000
1,160,000
0.11
47
5,330,000
5,750,000
420,000
0.081
48
4,700,000
5,120,000
420,000
0.098
50
5,940,000
6,080,000
140,000
0.038
Average gain 460,204
Average loss 0.084
Group
(c).
First count made
Second count made
Corpuscle gain or loss.
Col. index
gain or
loss.
ansesthesia.
before anaesthesia.
Gain.
Loss.
5
5,340,000
5,370,000
30,000
0.005
16
3,680,000
5,230,000
1,550,000
0.278
21
5,560,000
5,800,000
240,000
0.008
Average gain 740,000
Average loss 0.097
Group
{d).
First count made
Second count made
Corpuscle gain or loss.
Col. index
some time before
some time after
^
,
gain or
anaesthesia.
anaesthesia.
Gain.
Loss.
loss.
1
3,245,000
3,920,000
675,000
0.13
2
4,170,000
5,390,000
1,220,000
0.158
3
3,795,000
4,330,000
535,000
0.147
4
4,050,000
5,160,000
1,110,000
0.10
15
5,210,000
5,360,000
150,000
0.073
17
4,160,000
3,900,000
260,000
0.071
20
4,710,000
5,925,000
1,215,000
0.136
24
3,970,000
3,890,000
80,000
0.036
31
4,880,000
5,360,000
480,000
0.018
39
3,900,000
4,060,000
160,000
0.149
Average gain 520,500
Average loss 0.102
Leucocytes. The number of leucocytes varied greatly before
and after the operation. The average count preceding the
BLOOD CHANGES INDUCED BY ETHER. 9I
operation was 9898, and the average count following was
14,484, showing an average gain of 4586 per cubic millimetre.
In forty-three instances the leucocytes were increased, while in
five instances the number was decreased after the operation.
Classification of Cases.
So as to carefully compare the blood disturbances it was
found necessary to group the cases into four classes. This was
done in order to find what bearing the preparatory and post-
operative measures associated with the an?esthetic period have
upon the blood disturbances. In group A those cases are
included in which the first blood examination was made a short
time before anaesthesia (average, two hours and twenty-one
minutes) and soon after ansesthesia (average, four hours and
forty-one minutes). The cases included in group b were those
in which the blood examinations were made a short time
before the operation (average, two hours and fifty-one minutes)
and some tiitie after (average, twenty hours and fifty- nine
minutes). The cases in group c include those in which the
blood examination was made some time preceding the opera-
tion (average, four hours and sixteen minutes) and soon after
(average, four hours and sixteen minutes). The cases included
in group d were those in which the blood examination was
made a considerable time before (average, forty-one hours and
one minute) and some time after the operation (average, twenty
hours and three minutes).
In group a the result of the examination represents the
changes that immediately follow the anaesthetic state, the first
blood-count, however, being made after the preparatory meas-
ures of treatment had been instituted, and the second count
before the post- operative treatment had been fairly begun. In
group b the results in a general way show the effects of the
anaesthetic state and the post-operative treatment. The count
preceding the operation was, however, made during or at the
height of the preparatory treatment. In group c the results rep-
resent the blood changes which occur during the preparatory
treatment and during the ann^isthetic state. In group B the
92 DA COSTA AND KALTEYER,
results include the effects produced by the preparatory treat-
ment, the anti2Sthetic state, and the post-operative measures.
Fifteen cases were included in group «, 22 in group b, 3 in
group <:, and 10 in group d.
Number of Erythrocytes. The average gain per cubic milli-
metre in the number of erythrocytes in group a was 265,000;
12 cases in this class showed a gain in the number of colored
corpuscles, while there was a loss in 3 cases.
The average gain per cubic millimetre in group b was
460.204 corpuscles, and there was an increase in the number of
erythrocytes in 18 cases and a decrease in 4 cases.
The average gain per cubic millimetre in group c was
740,000 corpuscles. Every case in this group showed an in-
crease in the number of red cells.
In group d the average gain was 520,500 corpuscles per
cubic millimetre; 8 cases showed an increase in the number of
chromocytes, and 2 cases showed a decrease.
In series a Cases Nos. 9, 40, and 45 and in series b Cases
Nos. II, 14, 19, and 38 indicate that the preparatory treatment
produced marked concentration of the blood, which was prob-
ably at its height at the time of the first examination or a
short while after, and the blood became somewhat diluted be-
fore the second count was made. In the remaining cases of
series a and b the marked increase in the number of ery-
throcytes must be attributed to the blood inspissation. In
series c a gain in the number of chromocytes only was noted.
This was probably due to the fact that two of the factors which
produce blood inspissation — namely, preparatory treatment and
sweating during the anaesthetic period — were taken into consid-
eration ; the first count was made before the concentration. In
series d Cases Nos. 17 and 24 show that the equilibrium exist-
ing between the plasma and the corpuscles was being restored,
for the reason that the first blood-counts were made prior to the
preparatory treatment ; the figures may even represent an abso-
lute loss of chromocytes. In series a the average gain of
265,000 corpuscles appears to represent the degree of concen-
tration (over the inspissation induced by the preparatory meas-
ures) produced during the anaesthetic period. In series b the
BLOOD CHANGES INDUCED BY ETHER.
93
average gain of 460,204 cells per cubic millimetre represents
the degree of concentration produced during the anesthetic and
post-aneesthetic periods. In series c the average gain of 740,000
cells per cubic millimetre represents the concentration produced
by the preparatory measures of treatment and the anaesthetic
period. It will be noticed that the average gain in series c is
greater than in any of the other groups. The explanation for
this is probably that the period preceding the operation and the
anaesthetic stage produced the highest degree of inspissation.
In series c the average gain was 520,500 per cubic millimetre.
This increase in the number of corpuscles represents the degree
of inspissation produced by the three periods. It is apparent,
however, that this gain is not so striking as the gain in series c,
probably for the reason that blood dilution has been active
in some of the cases before the last examination.
Hcsmoglobin. The haemoglobin gain and loss when analyzed
in regard to the four periods, a, b, c, and d, shows varying
results. In some instances the haemoglobin appears to have
increased ; this apparent increase being due to blood concen-
tration. In some instances the hemoglobin appears to have
decreased. This necessarily represents an absolute decrease.
When the total blood value is fluctuating the gain and loss of
hemoglobin is best determined by studying the individual
corpuscular value in haemoglobin.
Duration of
^0.
operation.
37
90 minutes
41
75
13
65
6
60
9
60
36
38
29
37
40
35
13
30
45
30
44
25
49
25
8
24
10
23
7
12
Table IV.
rt time before and
soon after anaesthesia.
Corpuscular
gain or loss.
Loss of color
index.
Gain.
Loss.
820,000
0.091
70,000
+ slight
990,000
0.203
120,000
0.026
130,000
0.052
635,000
0.02
420,000
0.104
210,000
0.024
660,000
0.032
470,000
0.059
450,000
0.09
200,000
0.105
170,000
0.0S4
430,000
0.132
25,000
0.06
94
DA COSTA AND KALTEYER,
(6) Blood examinations made a short time before and some time after
anaesthesia.
Duration of
Corpuscular gain or loss.
Loss of color
in(l6x.
so.
opcrRtion. ■ —
Gain.
Loss.
19
90 minutes
290,000
0.002
33
83
600,000
0.219
50
73
140,000
0.038
30
67
1,305,000
0.034
26
65
90,000
0.129
28
65
700,000
0.082
32
60
1,140,000
0.035
42
55
380,000
0.213
25
48
1,210,000
0.026
34
45
930,000
0.058
35
45
680,000
0.162
46
45
1,160,000
0.11
11
40
260,000
0.001
43
40
480,000
0.201
22
38
690,000
0.065
38
30
750,000
0.008
23
28
820,000
0.118
12
27
12,500
0.174
27
25
317,000
0.040
47
25
420,000
0.081
48
20
240,000
0.098
14
18
170,000
0.022
(e) Blood examinations made some time before and soon after anjesthesia.
Corpuscular gain or loss.
No.
21
5
16
Duration of
operation.
105 minutes
55
19
Gain.
240,000
30,000
1,550,000
Loss.
Loss of color
index.
0.008
0.005
0.278
(d) Blood examinations made some time before and some time after
anaesthesia.
Duration of
Corpuscular gain or loss.
Loss of CO
'0.
operation. r- -a. _
Gain. Loss.
index.
3
120 minutes . . . 535,000
0.147
4
120
1,110,000
0.10
20
95
1,215,000
0.136
15
90
150,000
0.073
39
90
160,000
0.149
17
60
260,000
0.071
2
47
1,220,000
0.158
1
35
675,000
0.13
24
35
80,000
0.036
31
25
480,000
O.OIS
BLOOD CHANGES INDUCED BY ETHER.
95
Table V.
(a) Blood examinations made a short time before and soon after
anaesthesia.
No.
Amount of ether used.
18
270
29
270
41
255
9
60
180
37
240
6
210
36
165
13
7.8
144
10
150
40
150
45
150
8
135
49
120
44
75.
7
7.2
c.
Corpuscular
gain or loss.
Loss of color
, ^.
index.
Gain.
Loss.
660,000
0.032
420,000
0.104
70,000
+ slight
130,000
0.052
820,000
0.091
120,000
0.026
635,000
0.02
990,000
0.203
430,000
0.132
210,000
0.024
470,000
0.059
170,000
0.084
200,000
0.105
450,000
0.09
45
25,000
0.06
(6) Blood examinations made a short time before and some time after
anaesthesia.
No.
Amount of ether used.
33
405 c.c
32
360 "
11
240 "
26
240 "
43
240 "
50
240 "
19
225 "
22
195 "
42
195 "
25
180 "
28
180 "
34
154 "
30
143 "
12
7.2
128 "
23
135 "
38
120 "
27
105 "
46
90 "
47
90 "
48
75 "
14
6.0
45 "
35
30 "
Corpuscular gain or loss.
Loss of color
Gain.
Loss.
600,000
0.219
1,140,000
0.035
260,000
0.001
90,000
0.129
480,000
0.201
140,000
0.038
290,000
0.002
690,000
0.065
380,000
0.213
1,210,000
0.026
700,000
0.082
930,000
0.058
1,305,000
0.034
12,500
0.174
820,000
0.118
750,000
0.008
317,000
0.040
1,160,000
0.11
420,000
0.081
240,000
0.098
170,000
0.022
680,000
0.162
96
DA COSTA AND KALTEYER,
(c) Blood examinations made some time before and just after anaesthesia.
Corpuscular gain or loss.
No. Amouut of ether used.
21 230 C.C.
5 188 " .
16 103 " .
Gain.
240,000
30,000
1,550,000
Loss.
Loss of color
index.
0.008
0.005
0.278
{d) Blood examinations made some time before and some time after
anaesthesia.
No.
Amount of ether used.
3
720
c.c.
39
330
1
195
20
180
2
165
4
165
31
150
24
120
17
105
15
75
Corpuscular
gain or loss.
Loss of color
index.
Gain.
Loss.
535,000
0.147
160,000
0.149
675,000
0.13
1,215,000
0.136
1,220,000
1,110,000
0.158
0.10
480,000
0.018
80,000
260,000
0.066
0.071
150,000
0.073
Color Index. In that series in which the blood was examined
just before and soon after the anaesthetic stage, the color index
value was reduced in every case but one. The average loss of
color index in this series was 0.077. This seems to clearly
demonstrate that there was marked blood destruction and also
increased blood production during the period of anaesthesia.
These conditions are indicated by the loss in the average, the
newly formed erythrocytes being deficient in coloring matter.
Although the blood was concentrated, the individual hemo-
globin value fell.
In every instance in series b the color index was reduced.
The average loss of color value was o 084. The average loss
in series b was more marked than the average loss in series a,
the reason for this probably being that rapid haemogenesis (of
cells deficient in hciemoglobin) progressed over a longer period,
as the second blood-count was made some time after the termina-
tion of the ancusthetic state. Therefore the average color value
reduction was more pronounced.
In series c the average loss of color index was 0.O97.
In series d the loss in the blood decimal was most pro-
BLOOD CHANGES INDUCED BY ETHER. 97
nounced — the average fall was o. 102. The explanation of this
marked decrease is the same as that given for the changes in
series ^, namely, that erythrocytic regeneration was further
advanced.
The constant loss in the color index is the most convincing evi-
dence of rapid blood destruction. This loss in the color value
occurred in groups a, b, c, and d. In only one instance, in
group a, was there a slight gain. In every other instance
there was a loss in the corpuscular haemoglobin value. If
the blood disturbance was due simply to concentration, the
rise and fall in the number of corpuscles and the percentage of
the haemoglobin should have been parallel, and the color index
would not have been changed. The reduction in the color value
of the corpuscles suggests rapid haemocytolysis and increased
haemogenesis.
The Duration of the Operation and the Quantity of Ether
Employed.
The results do not seem to show any direct relationship
between the blood disturbance and the duration of the opera-
tion. A similar statement may be made in regard to the quan-
tity of ether. Of course, it is obvious that a prolonged operation
upon a sound and vigorous patient will be tolerated better than
even a brief operation upon one who is weak and exhausted,
and also that some individuals will have much less blood destruc-
tion from the administration of a large quantity of ether than
others will from the inhalation of a small quantity. On account
of the many modifying factors it is difficult to determine the
exact influence which the quantity of ether and the duration of
the operation have upon the blood changes.
Blood Loss. The blood loss was very slight in nearly all of
the cases ; and in some there was practically no loss at all (eye
operations). It appears that the amount of blood lost did not
affect the blood changes to a perceptible degree. In Cases Nos.
7, 9, and 13, in group a, and Cases Nos. 12 and 14, in group
b, chloroform was used in conjunction with the ether. The
amount of chloroform employed was very small.
Am Surg 7
98
DA COSTA AND KALTEYER,
(a) Blood examinations made a sliort time before and soon after
ansesthesia.
Corpuscular gain or loss.
Loss of color
No.
Blood loss.
Gain.
Loss.
index.
6
loO c.c. .
120,000
0.026
41
120 "...
70,000
4-sliglit
9
90 "...
130,000
0.052
18
90 "...
660,000
0.032
49
90 " .
200,000
0.105
7
80 "...
25,000
0.06
8
15 "...
170,000
0.084
37 '
15 '• .
820,000
0.091
13
Small amount
990,000
0.203
10
Minimum
430,000
0.132
29
Bloodless
420,000
0.104
40
Bloodless
210,000
0.024
36
Bloodless
635,0(t0
0.02
44
Bloodless
450,000
0.09
45
Bloodless
470,000
0.059
{b) Blood examinations made a short time before and some time after
anaesthesia.
Xo.
Blood loss
11
120 c.c. .
19
120 " .
48
120 " .
26
90 " .
22
60 " .
35
60 " .
42
60 " .
47
60 " .
23
30 " .
25
30 '• .
28
30 " .
38
30 " .
46
30 " .
50
30 " .
43
15 i' .
32
15 " .
12
Small .
33
Small .
34
Trivial .
30
Very slight
14
Bloodless
27
Bloodless
Corpuscular gain or loss.
Loss of color
index.
Gain.
Loss.
260,000
0.001
290,000
0.002
240,000
0.098
90,000
0.129
690,000
0.065
680,000
0.162
380,000
0.213
420,000
0.081
820,000
0.118
1,210,000
0.026
700,000
0.082
750,000
0.008
1,160,000
0.11
14(t,000
0.038
480,000
0.201
1,140,000
0.035
12,500
0.174
600,000
0.219
930,000
0.058
1,305,000
0.034
170,000
0.022
317,000
0.040
{c) Blood examinations made some time before and soon after anaesthesia.
Gain. Loss.
No.
Blood loss
21
240 c.c. .
5
()( 1 " .
16
15 " .
Corpuscular gain or loss.
Loss of color
index.
240,000
0.008
30,000
0.005
1,550,000
0.278
BLOOD CHANGES INDUCED BY ETHER.
99
[d) Blood examinations made some time before and some time after
aniesthesia.
No.
Blood loss
3
478 c.c. .
4
300 " .
20
240 " .
2
90 " .
24
60 " .
lo
30 " .
39
30 '• .
31
15 " .
1
Slight .
17
Verv little
Corpuscular gain or loss
Gain.
.").">.'), 000
], 110,001)
1,215,000
1,220,000
1.50,000
100,000
480,000
075,000
Loss.
80,000
200,000
Loss of color
index.
0.147
0.10
0.136
0. 1.58
0.036
0.073
0.149
0.018
0.13
0.071
An Experiment upon an Animal.
The constant fall in the color index after anaesthesia suggested
the idea of experimental study in this line. It is our intention
to continue this work from an experimental stand-point. We
feel that the single experiment which has been performed is
worthy of mention, although we do not attempt to draw any
positive conclusions from a solitary observation. Two rabbits
were obtained, almost identical in point of age, size, and appear-
ance. One animal was etherized for two hours and twenty
minutes, 150 c.c. of ether being employed during the anaes-
thetic period.
A blood examination ten minutes prior to the beginning of
the etherization showed 6,140,000 erythrocytes per cubic milli-
metre; 79 per cent, haemoglobin, and a color index of 0.693.
The second blood-count was made thirty-nine minutes after the
beginning of the inhalation of the ether. This examination
showed 6,260,000 erythrocytes ; 69 per cent, haemoglobin, and
a color index of 0.592. The third examination was made one
hour and fifty minutes after the beginning of the etherization.
This count showed 7,000,000 erythrocytes ; haemoglobin, 69 per
cent., and a color index of 0.485.
The animal was then killed with ether.
A Summary of the Post-mortem Examination.
The serous cavities did not contain free fluid. The bladder
contained considerable urine, and the lower portion of the in-
100 DA COSTA AND KALTEYER,
testinal canal contained much thin fecal matter. The spleen
was small. The bone-marrow of the right femur was bright
red. Sections of the femur-marrow were fixed in Gulland's
formalin solution (formal, lo per cent, in absolute alcohol).
They were dehydrated in alcohol and infiltrated in paraffin.
The cut sections were stained with Ehrlich's triple stain (diluted
with four times its volume of water) for five minutes, washed in
water, then treated for a few seconds with methylic alcohol,
dehydrated in alcohol, cleared in xylol and mounted in Canada
balsam. Some of the sections were stained with h?ematoxylin
and eosin.
The other animal was killed by fracturing the spine. Upon
post-mortem examination all of the serous cavities contained a
small amount of fluid. The bone-marrow of the right femur
was not so red as was the marrow of the etherized animal, and
was somewhat firmer. Pieces of this marrow were treated
similarly to the marrow of the etherized animal. Upon micro-
scopical examination, by contrasting the marrow of the ether-
ized animal and the non-etherized, it appears that in the former
instance there is a marked cell proliferation, the cells being very
numerous and encroaching upon the normal fat spaces of the
marrow. The cell proliferation in the marrow of the etherized
rabbit involves particularly the erythroblastic elements ; these
cells are very numerous. These changes are exhibited in
Figs. I and 2.
As previously stated, we hesitate to draw any conclusion from
this single experiment, but nevertheless the very marked changes
that were found are suggestive of erythroblastic proliferation
as a result of the administration of ether. In the light of this ex-
periment it might be well to inquire if the pains in the limbs and
back, so common after antX-sthetization, are not due, at least in
part, to changes in the marrow.
We must not omit mentioning that the blood for examina-
tion was taken from the ear, and that during the entire an;cs-
thetic state probably 10 c.c. of blood were lost, so that the
changes found in the marrow might be in part due to the
hemorrhage.
Fig. 1.
Section of normal bone marrow of femur (of rabbit).
Fig. 2.
Section of bone marrow of femur (of rabbit) showing marked erythroblastic
proliferation after death by etherization.
blood changes induced by ether. loi
Conclusions.
1. The number of red corpuscles is influenced by many fac-
tors associated with and accompanying the anaesthetic state.
The character of this change is, as a rule, a polycythaemia,
rarely an oligocythremia. These factors associated with and
accompanying the anresthetic state may be grouped in three
classes, each of which when analyzed separately is capable of
producing an increase in the number of colored corpuscles.
2. The nature of this polycythaemia seems best explained
by a lessening of the watery elements of the plasma, thereby
reducing the total volume of the liquor sanguinis, and conse-
quently causing concentration of the blood. It seems reason-
able to infer that the polycythaemia is not influenced by exces-
sive proliferative change which probably occurs in hrematopoetic
tissues. The increased blood production is an effort of nature
to rapidly restore the destroyed cells.
3. The three periods or factors incident to the polycythaemia
are : (a) The period of preparatory operative treatment ; (b)
the anaesthetic state, and (c) the post-operative state.
4. The blood inspissation is, as a rule, most pronounced im-
mediately after the termination of the anaesthetic stage. (See
group c.) In some instances the anhydraemia may be in-
creased by each succeeding factor, or one of these factors may
exceed the other ; for example, the preparatory measures may
bring about such a high grade of concentration that during the
period of anesthesia the polycythaemia may be stationary, or
in a few hours may lessen somewhat. This variation existing
between the plasma and the corpuscles, although temporary —
for the economy adjusts the balance of the output and the
intake of the watery principles of the blood with wonderful
rapidity — should be regarded as too pronounced to be within
the physiological limits. The relative increase in the number
of erythrocytes is generally still present some time after the
operation (see group d) ; but not infrequently the adjustment
of the watery and solid elements manifests itself before this
time, and an oligocythjtmia may be present.
I02 DA COSTA AND KALTEYER,
5. The haemoglobin is always reduced absolutely; in some
instances there is an apparent increase, but this rise in the per-
centage of haemoglobin is never parallel with the rise in the
number of red blood cells. The individual corpuscular h;t2mo-
globin value is therefore reduced. This reduction in the color
value of the chromocytes is most striking when the color index,
ascertained some time before the operation, is compared with
the blood decimal, determined some time after the operation.
We must conclude that etherization produces increased hcEmolysis,
and in nature's effort to rapidly replace the destroyed corpjtscles,
the regenerated cells are imperfectly supplied xvith hcEinoglobin.
6. The duration of the anaesthetic state and the amount of ether
may influence the blood changes ; but the extent of the disturb-
ances could not be determined on account of the many modify-
ing factors.
7. The amount of blood loss as encountered in this series of
cases does not seem to demonstrably affect the results.
8. Whenever possible one or more blood examinations should
be made before giving a general anaesthetic, and the examina-
tions should be made before preparatory treatment has been
instituted.
On account of the haemolysis which is shown by the fall in
corpuscular haemoglobin after operation, a very low percentage
of haemoglobin must be regarded as a contraindication to
operation. The amount which should be regarded as a posi-
tive contraindication is uncertain. We think with Hamilton
Fish, that below 50 per cent, is a dangerous level. In malig-
nant diseases, and in cases where surgery might prolong life but
cannot cure, operation should not, as a rule, be performed under a
general anaesthetic if haemoglobin is below 50 per cent. We
have operated in two cases in which the haemoglobin was 40
per cent. In each instance a vital emergency existed, and in
each case death upon the table was narrowly averted. Mikulicz
sets 30 per cent, as the lowest level at which operation is to be
attempted. We would not give a general an;esthetic except
under the stress of absolute necessity, if the haemoglobin is
below 40 per cent. It is true cases are occasionally an.xsthe-
BLOOD CHANGES INDUCED BY ETHER. IO3
tized with success when there is less than 40 per cent. We
know of one case with 30 per cent, anzesthetized successfully,
and of another with only 24 per cent. ; but a few exceptions do
not disprove the rule. In cases with haemoglobin below 50 per
cent., if an operation is necessary, a local anzesthetic should be
used whenever possible.
Whenever the percentage of haemoglobin is low, if an opera-
tion is determined on, the ordinary preparatory measures should
be modified in every way in order to avoid creating an undue
drain upon the blood. If a general anaesthetic is given its
administration should be intrusted to an experienced man; as
little as possible should be given, and in many instances oxygen
should be combined with it. The operation should be per-
formed rapidly ; prompt measures should to taken to bring
about reaction after its completion, and' oxygen should be
inhaled to remove ether quickly from the lungs and blood.
STUDIES OF THE BLOOD IN ITS RELATION TO
SURGICAL DIAGNOSIS.
By R. C. CABOT, M.D., J. C. HUBBARD, M.D.,
AND
J. B. BLAKE, M.D.,
BOSTON.
Among the problems which we undertook to investigate dur-
ing the preparation of this paper sufficient material has for valid
inferences been secured only in four, viz. :
1. The effects of ether upon the leucocyte-count.
2. The effects of operation upon the leucocyte-count,
3. The effects of fractures upon the leucocyte-count.
4. The regeneration of the blood after operations for malig-
nant disease.
We shall present, however, some observations on the varia-
tions of the white-count in typhoid fever and after muscular
exertion, which seem to us of interest.
I. Leucocvtosis after Ether. The importance of deter-
mining whether leucocytosis is increased by ether narcosis is
obvious in the post-operative treatment of surgical cases. Dur-
ing this period the temperature-chart and leucocyte-count are
sometimes consulted for information regarding the progress of
the healing process and the possibility of septicaemia or of
deep-seated pockets of pus. It is obvious that if we are to draw
any conclusions from the leucocyte-count we must know, first,
whether ether per se has any tendency to produce leucocytosis ;
and, secondly, how much, if at all, the leucocytes are affected
BLOOD IN ITS RELATION TO SURGICAL DIAGNOSIS. IO5
by the operation itself aside from its later results. To deter-
mine these facts we have had the leucocytes counted :
(a) Before the ether was administered.
(d) After full anaesthesia, or before the beginning of the oper-
ation.
(c) After operation.
In this way we have investigated 50 cases. In a general way
our results tend to show that there is little if any leucocytosis
during the period just after full etherization and just before the
beginning of the operation, while after the operation there is
not infrequently a moderate increase of the white cells. Out
of the total 50 cases only 13 showed an increase of more than
2000 leucocytes after full anaesthesia, while in seven there was
an actual diminution in the leucocyte-count. The onh' cases in
which there was considerable increase after etherization are the
following :
No.
Operation
Before ether.
After ether
1.
Hernia
9,400
12,400
2.
Hernia
8,200
13,600
3.
Hernia
6,800
9,400
4.
Stone in the bladder
15,800
19,920
5.
Cancer in the cervix
12,400
17,000
6.
Ovariotomy
^
13,800
21,000
7.
Vaginal section
14,600
25,000
These results are in sharp contrast with those of Chadbourne,
who studied 21 cases and found an increase in every case, the
average being 37 per cent. He noted, however, that the leuco-
cytosis was most marked during the Jirst part of etherization^
and that the increase was exceedingly rapid, some cases show-
ing a change of 70 per cent, within a few minutes. Very pos-
sibly the subsequent fall toward the completion of the anaes-
thesia may have been equally rapid. The differential counts in
Chadbourne's cases showed that all varieties of leucocytes were
increased, the lymphocytes somewhat more than the others.
Chadbourne considers the leucocytosis to be due to the irrita-
' Philadelphia Medical Journal, February i8, 1899.
io6
CABOT, HUBBARD AND BLAKE,
tion produced by the ether vapor upori the respiratory tract.
Exhibited in tabular form, our results are as follows :
Table I. — Leucocyte-count before and after Ether Anaesthesia,
AND AFTER OPERATION.
:ases. Operation.
1. Litliolapaxy .
2. ? . .
3. Senile gangrene
4. Cancer cervix uteri
5. Appendix
6. Stone (kidney)
7. Excision elbow
8. Ether examination
9. Hernia .
10. Laparotomy .
11. Stricture urethra .
12. Hernia .
13. Gastro-enterostomy
14. Cholecystotomy
15. Gastrostomy .
16. Stricture urethra .
Appendicitis .
Hernia .
Inguinal hernia
Appendicitis .
21. Hernia, inguinal .
22. Abscess of rectum .
2.3. Litholapaxy .
24. Chronic mastitis
25. Tumor neck .
26. Hernia .
27. Empyema
28. Nephrectomy.
29. Enchondromata
30. Hernia .
31. Amputation leg
32. 8upra[)ubic cystotomy
33. Necrosis tibiie
Count
Count after
before
ether but
Count after operation.
ether.
before operation.
. 15,800
19,920
19,300 same day.
15,400 next morning
. 6,000
8,600
16,600 same day.
11,120 next morning
. 17,200
13,600
19,900 same day.
16,100 next morning
. 12,400
17,060
20,700 same day.
10,400 next morning
. 18,100
17,520
21,500 same day.
12,600 next morning
7,900
7,200
27,300 same day.
13,700 next morning
8,060
9,100
8,100 same day.
. 14,400
10,200
10,600 '
3, 660
5,600
10,900
. 17.000
17,400
14,400
6,0110
6,400
5,200
5,400
7,200 '
7,800
7,600
9,400
8,000
9,200
8,600
. 6,400
8,000
8,400
. 10,000
16,400
16,000
. 8,600
10,800
10,200
. 9,000
12,800
13,400
. 6,000
7,200
8,400 '
. 16,000
15,800
17,200 '
8,200
13,600
14,800
. 10,000
11,000
11,000 '
7,600
8,800
. 14,800
16,000
16,600
3,800
4,600
4,400
. 9,400
12,400
11,800
. 2,800
23,000 '
. 15,400
15,800
21,200 '
. 10,600
11,000
14,0U(t
6,800
9,400
. 10,000
12,800
8,600
. 20,400
22, 200
22,800 '
. 8,800
11,200
11,800
BLOOD IN ITS RELATION TO SURGICAL DIAGNOSIS.
107
Count
Count after
Cast
s. Operation.
before
ether.
ether but
before operation.
Count after c
)perati(
34.
Salpingitis
9,200
9,800
13,000 same day
35.
Laparotomy .
7,900
11,800
9,400
36.
Vaginal section
. l.^.tilMI
22,200
20,000
37.
Vaginal section
14,000
25,000
21,600
38.
Vaginal section
8,000
11,200
8,600
39.
Laparotomy .
13,000
15,000
18,000
40.
Hysterectomy (hemor'ge
) 8,900
10,000
19,800
41.
Ovariotomy .
13,800
21,000
21,400
12,200 next day.
42.
Healthy medical studen
t 10,200
11,000
9,400 same day
43.
Ischiorectal abscess
8,200
10,000
44.
Dilating and curetting
12,500
22,000
45.
Abscess of hand
14,000
20,000
46.
Ventral suspension
8,800
24,000
47.
Cervix .
8,500
9,200
20,000
48.
Hemorrhoids .
7,500
8,400
14,500
49.
Cervix .
7,800
10,400 '
21,400
50.
Vagina .
7,200
8,000
19,000
51.
Laparotomy .
8,200
25,000
52.
Breast amputation .
6,500
21,600
53.
Vagina .
8,000
24,000
54.
Amputation cervix .
7,000
8,800
11,500
55.
Dilating and curetting
6,800
8,200
19,400
56.
Tumor nose .
8,800
8,000
8,400
57.
Healthy medical studen
8,200
9,600
7,800
2. PosT-oPERATiVE Leucocytosis. After operation the leu-
cocyte-count was increased 2000 or more in 35 out of 47 cases,
and 3000 or more in 27 cases. This increase was in 24 cases,
or one-half of all, a relatively slight one, amounting, on the
average, to not more than 20 per cent., and in five cases there
was an actual decrease. In a few cases leucocytosis was con-
siderable, for example : (a) Case of stone in the kidney ; before
operation, but after complete etherization, 7200; four hours
later, after operation, 27,300 ; next morning, 13,700. Tempera-
ture, 101°. (<^) Nephrectomy. Before operation, but after ether,
15,400. After operation, 21,200. As a result of our counts in
47 cases, we conclude that operation has by itself a consider-
able tendency to increase the leucocyte-count in about one-half
the cases, while in the remaining half no leucocytosis of im-
I08 CABOT, HUBBARD AND BLAKE,
portance occurs. Regarding the duration of the post-operative
leucocytosis which occurred in our cases we have accurate notes
in only ten cases. In these it appears that within thirty-six
hours from the time of the operation the post-operative leuco-
cytosis has generally disappeared. In 7 of our ten cases the
count on the day following the operation was lower than on the
morning of the operation.
3. Fractures. Experiments have shown that a leucocytosis
can be produced in animals by a simple fracture. To inves-
tigate the possibility of a similar leucocytosis following fractures
in human beings, we have made 32 counts in 23 cases of simple
fractures, including 5 of the leg, 3 of the fibula, 2 of the ribs, 3
of the radius, i of the patella, i of the pelvis, i of the spine, i
of the astragalus, etc. In these cases there are 10 showing a
leucocyte-count of more than 10,500, but in only 6 did the count
reach above 12,000. The highest counts were 15,400 in frac-
ture of the pelvis, 14,800 in fracture of the leg. As a result of
these counts it would seem that simple uncomplicated fractures
seldom increase the leucocyte-count to any considerable extent.
In I case of fracture of both bones of the leg in which fat em-
bolism was suggested by lung symptoms and signs, the leuco-
cyte-count rose to 15,600, falling next day to 10,600. In one
case of fracture of the ribs with injury to the lung, the count,
made two days after the injury, showed 14,900 white cells.
A compound fracture of the leg, counted two hours after the
injury, showed only 5400.
Table II. — Leucocyte-count after Fractures.
Case. Bones broken. Count. Remarks.
1. ? . . . 9,200 same dav.
10,200 next day.
2. Fracture nose . . . 1-5,600 same day.
10,100 next day.
3. Colle.s' fracture . . . 10,800 same day.
4. Fracture tibia, comp. . 10,400 same day.
7,300 next day.
5. Fracture both bones leg . 6,8011 same day.
5,(MM) next day.
6 . . . G,4(Ml same day.
.'),9(H) next day.
BLOOD IN ITS RELATION TO SURGICAL DIAGNOSIS. IO9
Cast
'. Bones broken.
Count.
/ .
10,7<»0 same day.
S,4(K) next day.
8.
Fracture tibula
11,600 same day.
8,800 next day.
9.
Both bones leg
11,300 same day.
8,800 next day.
lit.
Fracture ribs
7,900 same day.
8,100 next day.
11
Fract. clavicle, ribs and scalp
9,900 same day.
8,600 2dys. later
12.
Fracture astragalus
10,800
13.
8,800
14.
Fracture fibula
11,200
15.
Fracture patella .
9,6tK)
16.
Fracture scapula .
12,500
17.
Fracture leg .
13,100
18.
Fracture astragalus
11,400
19.
Fracture fibula
8,600
20.
Fracture fibula
13,600
21.
Fracture pelvis .
15,400
22.
Fracture spine ...
14,600
23.
Fracture leg . . . •
10,100
24.
Fracture leg .
14,800
25.
Fr. clavicle, ribs, and injury to
lung ....
14,900
26.
Fracture leg, compound
5,400
27.
Fracture thigh
14,260
28.
Fract. arm, comp., and fract.
scapula ....
13,000
29.
Fract. skull, scalp wound
12,100
30.
Greenstick fract. arm (baby) .
15,200
31.
Impacted hip . . .
11,600
32.
Impacted fract. leg
6,600
33.
Impacted hip (4} wks. old) .
6,800
34.
Fracture b. b. leg (Feb. 2)
15,600
(Feb. 3)
10,600
35.
Pott's fracture
5,850
Remarks.
No ether, 2 days later.
No ether, 2 hrs. after.
Ether.
Ether.
No ether.
Ether.
Ether.
No ether.
Fat embolism ?
4. Blood Regeneration after Operations for Malignant
Disease. Bierfreund ^ makes the astonishing statement that
after operations for malignant disease the haemoglobin never
reaches the point at which it was before operation. To deter-
mine the correctness of this curious statement we examined
1 Langenbeck's Archiv, vol. xli.
no
CABOT, HUBBARD AND BLAKE,
thirteen cases of cancer and arrived at results wholly opposed
to those of Bierfreund. Thus, in a case of cancer of the breast,
the hjemoglobin of February 23d was 70 per cent., and on
March i8th, after operation, the haemoglobin was 85 per cent.,
and in 5 cases entering the hospital for a second time after a
recurrence of a cancerous growth, the haemoglobin averaged 8j
per cent. In no one of them was it markedly diminished.
Table III. — H.lmoglobix Regeneratiox after Operatioxs for
Malignant Growth.
Case.
Disease.
1. Mammary cancer
2. Mammary cancer
3. Cancer uterus
4. Cancer of cervix
5. Recurrent cancer in vagina
after hysterectomv in
August,' 190t».
6. Cancer left breast : recurrence
Hsemoglo-
Haemoglo-
bin before
bin after
Time elapsed.
operation.
operation.
Per cent.
Per cent.
70
70
10 days.
90
80-80
6 days.
80
90
4 days. This case simply
curetting and cauterizing
the growth.
90
80
10 days.
90
90
6 days.
90
7. Recurrent cancer ; second 90
operation.
8. Cancer breast
9. Cancer breast .
10. Cancer uterus, dermoid ovary
11. Second operation for osteo-
sarcoma thigh.
12. Malig. dis. of stomach, ex-
tensive cancer ; explo. lap.
13. Carcinoma of lip
90
90
80
80-90
90
100
9(1
50
80
90 Nov. 1896, Oct. 1899, re-
current nodules; removed
May and November, 1900.
Time elapsed 6 days.
90 — 8 days. First operation,
Feb. 1901 1 ; second opera-
tion, Nov. 1900.
Second oper. May 2, 1899.
Time elapsed 8 days.
Second oper. Dec. 1. 1900.
Count April 8.
18 days.
8 days.
45 22 days. General condition
worse.
80 8 davs.
5. Variations of the Counts in Cases of Typhoid Fever
Examined from Hour to Hour. In the writings of Cushing,
Thayer, and others considerable stress has been laid upon the
occurrence of a short wave of leucocytosis as suggestive of
perforation of the intestine. This wave of leucocytosis has been
BLOOD IN ITS RELATION TO SURGICAL DIAGNOSIS.
I I I
apparent in some cases only when hourly or half-hourly counts
were made, and would have been altogether overlooked had
counts been made only once or twice in twenty-four hours. It
appears to us that such a wave of leucocytosis may and prob-
ably does occur in many conditions other than intestinal per-
foration and even without any recognizable pathological lesions.
Thus, in a convalescent typhoid were recorded the following
counts: 4.15 p.m., leucocytes, 10,100; 5.15 p.m., leucocytes,
5800; 6.05 P.M., leucocytes, 9060. In a healthy subject, aged
thirty-one years, the following counts were recorded; 5.15 p.m.,
leucocytes, 5700; 5.30 p.m., leucocytes, 6600; 5.50 p.m., leuco-
cytes, 7700 ; 605 P.M., leucocytes, 8400(50 far is to be observed
a steady increase); 6.15 p.m.; leucocytes, 5400.
In view of these and similar variations observed in 10 other
cases (4 of which were cases of typhoid fever), we believe it is
unsafe to base any inferences regarding diagnosis and treatment
upon such temporary zvaves of leucocytosis. That leucocy-
tosis usually exists in typhoid perforation we are well aware,
but in order to be of diagnostic value such leucocytosis must
be relatively steady and not of the type described by Gushing.
Table IV. — Frequext Leucocyte-counts ix Typhoid Fever axd
IN Health.
Remarks.
Several hemorrhages before,
during and after count.?.
Xo perforation. Recovery.
Steady improvement after count,
Case
Diagnosis.
Hour.
Couut.
1.
Typhoid,
11.00 A. M.
8,200
12.00 ^i.
10,300
LOO P. M.
12,200
2.00 "
10,300
3.00 "
11,400
4.00 "
15,400
5.00 "
7,500
6.00 "
7.00 "
28,800
8.00 "
10,600
2.
Typhoid,
Whites
Entrance
6,300
8 dys. later
8,800
9.20 A. M.
10.25 "
14,300
12.20 p. M.
12,800
Boy, 15 years ; 12 days' duration
at entrance. At 6 a.m. sharp
abdominal pain ; no vomiting;
one hour later cliill; s.45.
112
CABOT, HUBBARD AND BLAKE,
Case
. Diagnosis.
Hour.
Count.
Remarks.
Sept. 15,
1.20 "
10,600
slight general distention ; 7,
2.20 "
8,400
subnormal, anxious expression;
5.20 "
10,600
pain. Parents refused opera-
8.10 "
14,300
tion. Sept. 17, 10.20 A. M.,
10.00 "
13,000
died. Symptoms of general
Sept. 16,
8.15 A. M.
20,200
peritonitis.
" 16,
10.00 "
22,000
" 16,
11.00 p. M.
18,800
" 17,
9.45 A. M.
9,000
3.
Typhoid.
13,300
Woman, 18 ■ 6th week ; sudden
pain and swelling leg ; phle-
bitis.
4.
Typhoid,
4,200
Boy, 16 years ; admitted Sept.
8.30 A. M.
8,600
14, one week's duration ; per-
1.30 p. M.
5,500
foration Sept. 26th, chill at
5.00 "
3,200
3.30 A. M. ; transferred surg.
8.00 "
5,000
Operated ; lived four days ; no
general peritonitis at operat'n.
5.
Typhoid,
Hourly
First
6,400
Five days before hemorrhage
Second
6,600
and death.
Third
6,000
6.
Typhoid.
3.45 p. M.
4.45 "
5.35 "
11,000
9,060
9,300
7.
Typhoid
4.00 p. M.
15,000
relapse,
5.00 "
5.50 "
14,400
11,400
8.
Convalescent
4.15 p. M.
10,100
typhoid.
5.15 "
6.05 "
5,800
9,060
9.
Typhoid,
4.30 p. M.
5.20 "
6.20 "
7,100
7,400
5,600
10.
Typhoid,
9.35 A. M.
10.00 "
10.25 "
11.25 "
7,300
5,100
5,700
6,850
11.
Typhoid,
1.00 p. M.
2.(10 "
3.00 "
6,600
6,600
0,800
BLOOD IN ITS RELATION TO SURGICAL DIAGNOSIS.
113
Count. Remarks.
11,000
9,200
7,000
10,100
5,700
6,600
7,700
8,400
5,400
Severe Muscular Exertion.
Finally, we think it may be of interest to put on record the
following observations made in four of the runners in a recent
" Marathon race " of about twenty-four miles, which took place
April 19, 1901. All the cases showed a very marked increase
in the white cells. In one case the leucocytes rose from 3700
before the race to 20,800 after it. (See table below.)
Case. Diagnosis.
Uour.
Normal health,
4.. 30 p. M.
4.45 "
5.00 "
5.15 "
Normal health,
5. 15 p. M.
5.30 "
5.50 "
6.05 "
6.15 "
6. Leucocytosis after
-
DiflFerential white count after the race
Leucocytes before
race.
Leucocytes
after race.
Polymorph, mona^and
neutroph. transit.
Small
mono.
1
o?S. Myelocytes
3 days before, 1
9800 ;
immediately |
before, 4800^ J
2 days before, \
5800^ /
Immediately "1
before. 3700^ /
3 days before )
8.30 p.m., \
8200* J
14,400
16,200
20,800
22,200
■
90.3 4.0
91.3 4.7
84.4 8.0
86.0 7.3
5.7
4.0
7.2
6.7
0
0
0.4
0
0
0
0
0
^ Reds normal ; no eosinophiles found in two coverslip spreads ; haemoglobin
105 per cent.
^ Haemoglobin 98 per cent. ; reds normal in size, some irregularity in staining.
Among the forms classed as polymorphonuclear neutrophiles were an unusual
number whose nuclei were but partly divided, and rarely one almost a myelocyte.
No typical myelocytes.
•' Hsemoglobin 90 per cent. ; reds normal.
* Haemoglobin 100 per cent. ; some variability in coloring of reds ; reds other-
wise normal.
Am Surg 8
114 BLOOD IN ITS RELATION TO SURGICAL DIAGNOSIS.
But still more interesting were the changes revealed by the
differential count, which showed a very marked, absolute, and
relative increase in the polymorphonuclear neutrophiles, with a
corresponding diminution of the lymphocytes and an entire
absence of the eosinophiles in three cases out of four, while in
the fourth they were greatly reduced. In one case atypical
forms of leucocytes not to be observed in normal blood were
present. The details of these counts are shown in the table on
preceding page.
To capitulate briefly :
1. At the end of complete anaesthesia there is occasionally
a slight increase of leucocytes, but seldom a marked leuco-
cytosis.
2. At the end of operation there is a considerable leuco-
cytosis in one-half the cases, and in almost all cases some
increase beyond that found at the end of complete anaesthesia.
3. Simple uncomplicated fractures seldom increase the leuco-
cyte-count to any considerable extent.
4. The blood after operation for malignant growths is not
necessarily much impoverished, and regenerates, in favorable
cases, quite normally.
5. A variation in the hourly leucocyte-count exists in other
conditions than the preperforative stage of typhoid, and may
occur in health.
6. Very violent physical exertion produces in the blood a
condition which leaves physiological limits and approaches or
is identical with that found in disease.
The writers desire to thank the staff of the Massachusetts
General Hospital, the Boston City Hospital, and St. Elizabeth's
Hospital for permission to study cases under their care. At the
Boston City Hospital white counts were made by Mr. W. H.
McBain, Mr. D. A. Hefferman, Dr. J. H. Mullin, and Dr. R. C.
Thompson ; at St. ^Elizabeth's Hospital, by Drs. J. J. Sullivan
and T. F. Hanna. Differential counts of Marathon runners, by
Dr. R. C. Larrabee.
THE EXAMINATION OF THE BLOOD IN RELA-
TION TO SURGERY OF SCIENTIFIC BUT
OFTEN OF NO PRACTICAL VALUE,
AND MAY MISGUIDE THE
SURGEON.
By JOHN B. DEAVER, M.D.,
PHILADELPHIA.
The object of this paper is not to decrythe value to the sur-
geon of examinations of the blood, for we undoubtedly can by
this means often obtain valuable information as to the nature
and progress of pathological conditions that can be obtained in
no other way. Yet valuable as this sign is, its usefulness is
confined to quite narrow limits, and even in its proper field its
significance is frequently very difficult and sometimes impos-
sible to determine.
The blood-count is a valuable physical sign, but it is, how-
ever, only one sign, and should be kept in its proper perspec-
tive. One spot is not sufficient evidence upon which to base a
diagnosis of typhoid fever, nor can the presence of pus be
asserted or denied from an estimation of the number of leuco-
cytes alone.
In the last few years there has crept into the profession a
tendency to replace the bedside by the laboratory as the point
from which to make the diagnosis ; to substitute the highly
magnified but extremely limited field of the microscope for the
broader view of the eye of the physician. This we regret, for in
the majority of instances the diagnosis must be made at the bed-
side without the aid of the microscopist, and any man who has
no confidence in diagnoses made without the aid of the labora-
tory limits his usefulness.
Il6 DEAVER,
The blood-count theoretically promises the surgeon more
perhaps than any other of the lines of laboratory investiga-
tion, and is certainly of great practical value, yet the informa-
tion thus obtained is open to many fallacies, and the surgeon
who depends on this means alone to decide for or against opera-
tion in any condition is often acting to the detriment of his
patient.
The technique of a blood-count is one in which there are
opportunities for inaccuracies without number, and the dilution
with which it must be made multiplies each error a hundred-
fold. Therefore, except in the hands of an expert, its evidence
is always open to a reasonable doubt, and even with an expert
it is only on repeated examinations that absolute dependence
can be placed.
The secret of life-saving surgery is promptness in diagnosis
and operation, and often the time lost in awaiting the confirma-
tion of our opinions by the laboratory can be ill afforded by
the patient.
An effort has been made lately to determine the exact degree
of anaemia below which it is unwise to attempt a surgical opera-
tion. In this we are asking more of a blood-count than it will
ever be able to give. In medicine we are dealing with living
organisms, with widely varying powers of resistance, and there-
fore the degree of anaemia compatible with successful surgery
will vary with each patient. Then, too, what the operation
promises is another important factor; for we are certainly justi-
fied in attempting an operation which, if successful, will restore
our patient to health under conditions that would positively
forbid a merely palliative operation.
To illustrate this, let me briefly cite two cases that have
recently occurred in my practice.
Case I. — Mrs. L. B., aged fifty-five years, was admitted to the Ger-
man Hospital December 20, 1900, and the following history obtained :
Family and previous histories negative. Menstruation physiological
until three years ago, when she apparently reached the menopause in
a perfectly normal manner. After an interval of eight months an exces-
sive metrorrhagia appeared, accompanied by a profuse offensive leucor-
THE BLOOD IN RELATION TO SURGERV. 11/
rhoea. One year later a fibromyoma was expelled from the uterus ;
this was followed by a temporary improvement, but six months later
the symptoms were as bad as ever, and she has steadily and rapidily
lost strength and weight ever since.
On admission the patient is extremely emaciated, with that bronz-
ing of the skin very suggestive of malignant disease, and so weak that
she is hardly able to raise herself in bed. She has a very offensive leu-
corrhcea and an almost constant metrorrhagia. A large, hard mass can
easily be made out connected with the uterus and rising above the
symphysis pubis.
The cervix is patulous, and presenting at the internal os can be felt
a large fibroid.
On the day after admission her blood-count was haemoglobin, 27
percent.; erythrocytes, 4,070,000; leucocytes, 5200. She was put
upon appropriate treatment, but showed only the slightest improve-
ment. On December 31, 1900, the blood-count was haemoglobin, 30
per cent.; red blood-cells, 3,980,000; whites, 5400. Despairing of
much improvement by delay, she was then operated upon. A large
multinodular uterine fibroid was removed by an abdominal pan-
hysterectomy and the wound closed without drainage. Conval-
escence was uneventful, and the patient left the hospital February 11,
1901, in good health. She has been seen within the last two weeks
and reports herself to be perfectly well.
Case II. — Mrs. M. C, aged forty-eight years, was admitted to the
wards of the German Hospital with the following history : A brother
died of cancer of the stomach, but the family history was otherwise
negative. Previous personal history negative ; menstruation always
physiological. No metrorrhagia or excessive menorrhagia. For the
last six years has been conscious of a mass in the lower abdomen, and
during this time has lost about forty pounds in weight. For the last
two years has been extremely weak and short of breath.
Examination on admission shows the patient to be a tall, thin
woman, with all the inspection symptoms of carcinoma. A soft,
blowing murmur is heard at the base of the heart. The blood-count
on the day of admission was haemoglobin, 22 per cent.; erythrocytes,
2,980,000; leucocytes, 5200. A large mass could be felt in the lower
abdomen, both by vaginal and supervaginal palpation.
She was operated on the next day and a large fibromyoma removed
by an abdominal pan-hysterectomy ; wound closed without drainage.
Il8 DEAVER,
Convalescence was uneventful, and the patient left the hospital Feb-
ruary 2, 1900, in very good condition.
Grave anaemias are, of course, a general contraindication to
an anaesthetic and operation in the same way that organic
heart lesions and nephrites are, yet we all know how often the
severest operations are successfully performed in the presence
of these complications.
Sometimes in a patient suffering from prolonged suppuration,
frequent hemorrhage or other conditions that would lead us to
expect a profound anaemia, we find either a normal or abnor-
mally high percentage of haemoglobin and erythrocytes. Such
results are very often misleading, as they by no means express the
blood condition of the patient. The chief cause leading to this
artefact is a transient concentration of the blood due to a les-
sening of its fluid constituents from purgation, excessive vomit-
ing, or free sweating. In addition to this, a stasis in the periph-
eral circulation from either organic heart disease or functional
depression from profound tox^iemia will raise the blood-count
above the true measure of the patient's anaemia.
The significance of the presence or absence of a leucocytosis
is perhaps the part of this subject with which we as surgeons
are most often concerned.
Without going into the discussions that have recently arisen
on this subject, we can consider the phenomena of leucocytosis
as primarily one of phagocytosis, it making no difference
whether the toxic materials are directly taken up by the
leucocytes or neutralized by a substance formed in part by
their activity.
If poisons of certain kinds are in the general circulation
there is ordinarily a general leucocytosis, its grade depending
largely on the resisting powers of the individual and the amount
and kind of poison.
Sometimes a sudden and overwhelming dose of septic poison
will so depress the patient that there is no phagocytic reaction
and a leucocytosis does not appear. Then, too, in prolonged
suppurative processes, with free absorption of the septic poison
THE BLOOD IN RELATION TO SURGERY. II9
at first, there is an active phagocytosis with a large leucocytosis,
but as the powers of resistance of the patient sink the leucocytosis
becomes very insignificant ; or, as time goes on, the focus of sup-
puration maybe shut off by nature from the general circulation,
and again the number of leucocytes fall.
In a general way high grades of leucocytosis are most com-
monly satisfactory signs ; while they are due to severe infection
they usually mean good reaction. Moderate grades of leuco-
cytosis, if the other signs of infection are severe, are in them-
selves suggestive of a bad result ; if the other signs of infection
are slight a mild leucocytosis means nothing of itself
If the origin of the infection is in a part of the body rich in
lymphatics and rapid in absorption, other things being equal,
the leucocytosis will be more marked. Thus it is that a peri-
tonitis gives a greater leucocytosis than a- pleurisy and why the
upper part of the peritoneal cavity if infected gives a quicker
and more profound systemic infection than the lower.
Of course, in a streptococcus infection, per se, we would get
a higher grade of leucocytosis than in a staphylococcus ; yet, as
we have shown, the degree of leucocytosis is so dependent on
the amount of poison absorbed and the resistance of the
patient that we can form no judgment as to the character of
the infection from the blood-count.
For years the text-books have nearly all contained the state-
ment that there is commonly a leucocytosis in cancer. On
what this is founded we do not know, for anyone with any
practical experience in this matter must know that such is not
the case, a leucocytosis in this condition being very uncommon,
and does not seem to be influenced by metastasis. Only nine-
teen out of forty-nine patients at the German Hospital suffer-
ing from carcinoma gave a leucocyte-count of over 10,000, and
only two of these were above 20,000, these two being respec-
tively an ulcerating carcinoma of the breast, which gave a
blood-count of 31,500 leucocytes, and a carcinoma of the liver,
with 40,800 leucocytes.
In cases of appendicitis we cannot depend on the blood-count
for our indication for operation, for the favorable time for this
I20 DEAVER,
operation is in the first hours of the attack, when the chief
symptoms are those of appendicial colic, and before severe
systemic infection has taken place. In these cases we often
have rupture of the appendix or transmigration of organ-
isms so suddenly infecting, in an overwhelming manner, the
entire peritoneal cavity that a leucocytosis is not established, or
is very evanescent, owing to the rapid paralysis of the resisting
powers of the individual. Or, as the symptoms improve and
the leucocytosis falls, we might think that the appendix was
becoming normal again, when the truth was that an abscess had
only become localized and no more septic material was being
absorbed. If, acting on this supposition, we should decline to
operate we would leave our patient exposed to the greatest risk
of a secondary outbreak that would be very likely to cost him
his life.
We will be doing much better surgery if we promptly operate
on our appendicitis cases than if we waste time over a blood-
count that, as is shown by Dr. Da Costa's paper, read before
you, is of very little value.
In the experience of the author in cases of salpingitis, even
quite moderate grades of leucocytosis (14,000 to 17,000) are in-
dicative of the presence of pus. Yet this is by no means con-
stant, for nature is so well able to care for these cases that
often large collections of pus are present without a leucocy-
tosis, much to the embarrassment of the surgeon who depends
upon the blood-count alone to show the presence of suppura-
tion.
In cases of obstructive jaundice a leucocytosis is usually but
not always present, and in our experience seems to be most
often due to a local peritonitis around the gall-bladder. In 8
out of 14 cases of obstructive jaundice due to gallstones a leu-
cocytosis was present.
Although I have not the data at hand to verify this statement,
I will venture the opinion that the most virulent of micro-
organisms may inhabit the altered bile of an occluded gall-
bladder without giving systemic signs, thus explaining many
cases of peritonitis after gallstone operations, in which the
THE BLOOD IN RELATION TO SURGERY. 121
operator, thinking the bile sterile, has allowed it to soil the gen-
eral abdominal cavity.
Pohl/ Wilkinson,- and Boland'^ have done some very interest-
ing work in regard to drug leucocytosis. These investigators
have found that many drugs have the power of producing a quite
marked leucocytosis ; among these quinine, the salicylates, anti-
pyrine, phenacetin, pilocarpine, Dover's powder, and morphine;
all drugs that our patients may have been taking at the time
we are called upon to make a diagnosis.
We might go on showing many other instances of surgical
conditions in which the blood-count is of doubtful value, or at
any rate disappointing; but we have, we think, said enough to
define our position.
We believe that if we have a decided leucocytosis (20,000 or
over) after excluding pneumonia, leukaemia, etc., we can safely
infer the presence of pus. Yet without a leucocytosis we can-
not be sure that pus does not exist. We also consider ex-
quisite tenderness, temperature, pulse, and the general appear-
ance of the patient as much more reliable guides than the blood-
count.
Therefore, gentlemen, we wish to say, in conclusion : let us
have blood-counts made on our patients. We have already
learned valuable lessons from them, and undoubtedly will learn
more in the future ; but let us not be drawn aside by their still
uncertain evidence from the lessons learned by practical expe-
rience at the bedside.
In the preparation of this communication I wish to credit
Dr. Edward Kemp Moore, my ex-house surgeon, for the
greater part of the work thereon.
• Archiv fiir exper. Path, und Pharmak., vol. xv., 1889.
2 British Medical Journal, September 26, 1896.
3 Centralblatt fiir innere Medicin, April 5, 1900.
BLOOD EXAMINATIONS AS AN AID TO SURGICAL
DIAGNOSIS.
By JOSEPH C. BLOODGOOD, M.D.,
BALTIMORE, MD.
Shock and Hemorrhage. Observations have demonstrated that
there is a leucocytosis of 15,000 to 24,000 following hemor-
rhage. As a rule, this comes on within a few hours. There are
not sufficient observations to demonstrate the relation between
the amount of blood lost and the leucocyte-count. We have not
sufficient data to clearly determine the exact changes in the
number of white blood-cells in shock from injury alone with-
out loss of blood.
Following hemorrhage, in addition to the rise in the number
of leucocytes, there is a diminution in the number of red blood-
cells and the percentage of haemoglobin. In severe hemorrhage
a blood-count will indicate to a certain extent the amount of
blood lost, but as a rule not until six or more hours have inter-
vened after hemorrhage.
The examinations of the blood after contusion of the abdo-
men, to ascertain, if possible, whether we can distinguish by the
changes in the elements of the blood the difference between
shock from the injury alone, internal hemorrhages, and perito-
nitis from rupture, are not sufficient in number to allow any con-
clusions.
Cabot' writes : "Often one hears the question discussed in
any accident-room in any hospital whether to operate at once
or wait until the patient has got over the shock. The question
' Clinical Examination ot the Blood, William Wood & Co., New York, 1898, and
International Text-book of Surgery, Warren and Gould, 1900, vol. i. p. 81.
BLOOD EXAMINATIONS AND SURGICAL DIAGNOSIS. I23
is not often asked, far less answered, whether the shock is simple
or largely anaemic (cerebral or general) from loss of blood, or
whether it is of nervous origin — /. e., due to concussion or com-
pression. The right decision of this question is of great im-
portance, for if the shock means anaemia, transfusion may be
indicated, while in a condition of cerebral concussion or com-
pression, transfusion will probably do harm." (Authorities do
not agree with Cabot. Transfusion is not contraindicated.')
"An examination of the blood enables us in certain cases to
decide such a question — that is, if the number of red cells is
considerably diminished (3,500,000 or less) and the patient is
known not to have been previously anaemic, the shock probably
means hemorrhage." " The blood-count may enable us to
gauge approximately the amount of hemorrhage. Here it
should be remembered, however, that immediately after hem-
orrhage the count may be normal, since only the amount and
not the quality of the blood is affected. Within a few hours,
however, fluid is absorbed from the tissues into the vessels, and
then an an^Emia will be indicated by the blood-count." "An
internal or cerebral hemorrhage, a rupture of an extra-uterine
pregnancy, ruptured aneurism, laceration of the spleen, kidney,
or liver, etc., can sometimes be diagnosed by the blood exam-
ination."
McLean," in his article entitled " Examination of the Blood
in Surgical Diseases," practically adds nothing new to Cabot's
statement in regard to the blood examination in shock.
The Importance of a Careful Blood Examination Preliminary
to General Anesthesia. There are now sufficient observations to
demonstrate pretty conclusively that in marked anaemia, espe-
cially when the haemoglobin percentage is low, that general
anaesthesia, especially if prolonged, is dangerous. Some author-
ities give 50 per cent., others 40 per cent. ; but the majority
agree that 30 per cent, of haemoglobin is a danger signal, and if
possible the operation should be delayed until appropriate treat-
' Progressive Medicine, December, 1900, p. 108.
2 Medical News, December, 1899, vol. Ixxv. p. 713.
124 BLOODGOOD,
merit has been used to increase the percentage of haemoglobin
and the number of red blood-cells.
This important subject has been studied by Cabot/ Da Costa,
Mikulicz, Hamilton Fish," and others.
My own experience has been sufficient to indicate the truth
of their statements. An anaesthetic has great additional dangers
when given to patients with the haemoglobin estimate below 50
per cent.
Post-operative Leucocytosis. There is need for much more
study on this question. Most authorities agree that following
ether there \s perhaps a slight increase in the leucocytes, which,
however, disappears within twenty-four and at most thirty-six
hours. In operations with much loss of blood there would, of
course, be a temporary rise in the leucocytes ; but, on the whole,
in the average operation one should expect the leucocytes to be
within the normal limits — twenty-four hours after operation. If
this is true, a sudden rise in the leucocytes would indicate some
post-operative complication. In abdominal surgery it would
suggest peritonitis, although if the peritonitis was a very grave
infection the leucocytes would soon fall rapidly. Perhaps the
leucocyte count as an aid to the post-operative diagnosis in
abdominal surgery is most certain in the early recognition of
obstruction. Here there is always a rise, usually over 20,000,
associated with any obstruction of the intestines. This rise
generally takes place within from eight to twenty hours after
the beginning of the obstruction, and in a few cases observed
the rise in the leucocytes had been prominent before the clinical
symptoms themselves were sufficiently clear to make a positive
diagnosis. The number of observations so far have demon-
strated that when, after laparotomy with general anaesthesia,
the patient develops slight distention, or even marked disten-
tion, with nausea and vomiting, which seems more or less due
to paralysis of the intestines, and not to a definite obstruction
or peritonitis, the leucocytes do not rise, at least not above 12,000
to 15,000. If these observations are confirmed, the counting of
' Loc. cit. "^ Annals of Surgery, 1899, vol. xxx. p. 79.
BLOOD EXAMINATIONS AND SURGICAL DIAGNOSIS. 12$
the white blood-cells would be a great aid in the differential
diagnosis in the first twenty-four to forty-eight hours or later,
after laparotomy, between benign abdominal distention and ob-
struction or peritonitis, for which operative interference would
be indicated early. This is apparently a closer relation between
the extent and character of the operation and the post-operative
leucocyte count than the anaesthetic. A more complete report
on this is in preparation, and will be published later.
Post- operative Phlebitis. In a few cases observed there is a rise
in the leucocytes, varying from 15,000 to 20,000. Such a leu-
cocytosis has been observed frequently in typhoid phlebitis ; but,
on the whole, the observations of the changes in the leucocytes
after operation are not well established.
If the phlebitis is confined to the iliac veins the first symp-
toms are those of an acute abdominal lesion, viz., localized pain
and slight muscle spasm in the iliac fossa ; nausea and vomit-
ing. If on the right side, after operation, the condition might
simulate an appendicitis, or, in women, a salpingitis. In typhoid
fever the early clinical picture is very much like intestinal per-
foration. A case of this character has been reported by Harvey
Gushing;' also by William S. Thayer,^ in his article entitled
" Observations of Blood in Typhoid Fever."
The Importance of the Leucocyte-count in the Early Recognition of
Acute Abdominal Lesions. The discussion of this subject is the
chief theme of this paper, not only because of its importance,
but, fortunately, in this field we have more observations.
Explanation of Table. The following table represents all the counts
made on cases of appendicitis. The first count in practically every in-
stance was made when the patient was first admitted to the hospital, and
this count is placed under the time corresponding to the number of hours
or days since the beginning of the acute attack ; subsequent counts (if
made) are noted by dotted lines after the first count under the proper
time. In the cases operated upon the last count represents the time of
the operation, with one exception, in the group appendicitis, general
1 Johns Hopkins Hospital Bulletin, No. 92, November, 1898.
* Johns Hopkins Hospital Reports, vol. viii., 1900.
126
BLOODGOOD,
peritonitis, operation. The letters Op. under the figure 20 represents
the time of operation. The three subsequent counts are post-opera-
tive, and show the fall in the leucocytes, with general peritonitis.
Under the column appendicitis, abscess, operation, there are only single
counts.
Hours.
Days.
Weeks.
Month
!
II.
III.
IV.
V.
VT.
6 to 14 16
20
24 30
36
40
48
to
III.
to
IV.
to
V.
to
VI.
to
VII.
lto2
2to4
1
Chronic and subacute appiendicitis.
75
10
.10..
75
5
6
12
12
Acute appendicitis. Xo operation. Recovery.
i 7^ -12
77-1 , -13-
\22 i -16-
17.
11
9
...7... I ...6
172-8 1
8-n-
17
Acute diffuse appendicitis. Operation. Recovery.
I 77 9
12
13
18
13
17
25
Gangrenous appendicitis. Operation. Recovery.
17
73__16--24--7 7-
13 '23 25
2/
74-1-20-17
13
r I
Acute appendicitis distended with pus. Operation. Recovery.
15
19
7 7-20
27-28
78-24 -35 (5 hours)
Appendicit
is. Abscess. Operation.
11 1
1
11 11
12
12 i 11
8
(-) 6
18 1
19
20
16
24 12
14
7
!
22
26
16
26 , 14
(2)17
8
1
27
30
29 (2)15
(•^)18
(2)19
25
27
, 30
(=-')18
19
25
60
(-')12
(2)15
(2)18
19
29
(2)28
Appendicitis. General peritonitis. Operation.
14
32
36
25
R
R
R
D
8-
20
Op.
23
26
11
D
11
D
n
D
13
D
14
D
17
R
21
D
24
D
25
D
40
D
(2) 9
(3)11
14
16
18
19
BLOOD EXAMINATIONS AND SURGICAL DIAGNOSIS. 12/
The figure 2 or 3 in front of the figures, representing the number
of leucocytes, indicates that there were two or three cases with this
number of leucocytes at this time. Under the column appendicitis,
general peritonitis, operation, the letter R indicates the patient recov-
ered, and D the patient dead. The time in these cases represents the
entire interval of the acute attack, and not the duration of the peri-
tonitis, which, in the majority of cases, was impossible to ascertain.
Leucocytosis in Appendicitis. When observed within forty-
eight hours the number of white blood-cells is in a majority of
instances of great value, indicating the extent of the inflamma-
tory condition of and about the appendix. This fact is well
illustrated in the table.
Chronic and Subacute Appendicitis. Sixteen counts. Here
we have cases of recurrent appendicitis, or of appendicitis suf-
fering from the first attack ; first observed practically at the end
of the attack, when the clinical symptoms were subsiding or
practically over. The almost uniform low leucocyte-count,
even in this small group of cases, is very suggestive that such
an observation is an important additional aid to recognize that
an acute attack of appendicitis is subsiding; or when seen later,
after the clinical signs have entirely disappeared, the absence of
leucocytosis should be considered a distinct factor in excluding
an abscess. It is noticed in the table that the highest count in
this group of cases was 15,000. In i admitted thirty-six hours
after the beginning of the attack, and in which the local clinical
symptoms were distinctly less according to the statement of the
patient, and which when admitted were just sufficient to suggest
an appendicitis, observed — these slight local symptoms disap-
peared, associated with a fall in the leucocytes to 10,000 and
6000. A later operation demonstrated a diffuse thickened
appendix, but no pus. Observed between the second and
seventh day, the leucocyte-counts have been 15,000 in 2 cases,
10,000 in 2 cases, in i falling to 7000, and in i case 11,000.
With b2it a few exceptions these are distinctly lower counts than
in the other groups of cases. In all of these cases, at an
operation performed later, a simple diffuse appendicitis was found
with no pus or evidence of infection outside of the appendix. In
128 BLOODGOOD,
10 cases observed from one week to one month after the last
acute attack, in only 2 cases were the leucocytes as high as
12,000, the remainder were 9000 and lower. In the majority of
these cases there were no clinical symptoms, simply a history
of one or more previous attacks. At the operation a diffuse
appendicitis was found, with no evidence of pus outside of the
appendix.
Comparing this group with cases of appendicular abscess ad-
mitted from one week to one month after the beginning of the
attack (33 cases) we see distinct differences. In those cases with
abscess, only 6 out of the 33 cases had leucocyte-counts below
12,000. Some of these 33 cases of abscess exhibited no clinical
evidence of tumor. This observation demonstrates that in cases
of appendicitis admitted late in the attack a high leucocyte-count
is almost a positive evidence of an abscess, even when the clini-
cal symptoms have entirely subsided and the abdominal exami-
nation is negative. In a few cases, but only a few, we may ex-
pect to find a small localized abscess even when white blood-
cells show no marked increase ; but this is a rare exception to
the general rule.
Future observations may demonstrate that the leucocyte-
count will aid us in indicating the better time to operate in cases
of appendicitis with abscess. Many of these patients come to
the hospital at the end of the attack, the clinical symptoms are
subsiding or have ceased, and we usually find on abdominal
palpation an area of tumor or induration, suggesting a localized
collection of pus, which in some instances, however, proves to
be a mass of adherent omentum. Now and then in such cases
when we have delayed we have found that the localized pus has
become much inspissated and the virulence of the organism may
have decreased. Experience would seem to demonstrate that
if the pus is distinctly localized and the symptoms on the de-
crease, it is, perhaps, the safer plan to delay the operation to a
date when the difificulty of removing the appendix and the
danger of infecting the general peritoneal cavity would be
less. Our cases require a more minute study before such a
conclusion can be demonstrated.
BLOOD EXAMINATIONS AND SURGICAL DIAGNOSIS. 1 29
Acute Appendicitis. No Opemtion. Recovery. In the cases
admitted within forty-eight hours with acute symptoms, if on
on account of the clinical picture operation has been delayed,
we have always observed a falling leucocytosis. These patients
have recovered, and at a later operation the appendix is found to
be the seat of a diffuse inflammation, but there has been no
evidence of pus outside the appendix. In i case admitted six-
teen hours after the beginning of the attack the leucocytes fell
in ten hours from 17,000 to 13,000, and in twenty-four hours to
1 1,000, associated with the disappearance of the symptoms. With
one exception the highest first leucocyte-count in this group
has been 17,000, falling in a few hours to 12,000, 9000 or even
lower. A patient admitted twenty hours after the beginning of
the acute attack had a leucocytosis of 22,000. The clinical
symptoms, however, were not very marked. The patient was
observed eight hours ; during this period the leucocytes fell to
16,000, and the local symptoms practically disappeared. Within
the next twenty-four hours the leucocytes were 11,000, then
8000, 7000, then 6000. Athough this patient with a leucocy-
tosis of 22,000 at the end of twenty hours recovered, and there
is every reason to believe that the inflammatory condition about
the appendix subsided, nevertheless it is an exception to the
general rule, and it would be safer, I believe, to operate in those
cases of acute appendicitis observed within the first forty-eight
hours with a leucocytosis of 20,000.
Acute Diffuse Appendicitis. Operation. Recovery. Eleven cases.
The leucocyte counts in this group of cases do not differ much
from those in the group of acute appendicitis which were not
operated on until after the end of the acute attack; and of course
it is a question whether all of these cases might have recovered
from this attack without operation. It is to be noted that in
one case observed in the hospital the leucocytes rose from 8000
to 18,000; and a second from 13,000 to 17,000. In three cases
there was a fall in the leucocytes from 10,000 to 7000 ; from
11,000 to 9000, and from 14,000 to 10,000. In two cases ob-
served at the end of two days and five days it was a question
whether the patient was getting over the attack or not, but it
Am Surg 9
130 BLOODGOOD,
was considered wiser to operate. A simple diffuse appendix
was found. In the third, admitted twenty hours after the be-
ginning of the attack and observed four hours, the patient
clinically was distinctly getting worse, the leucocytes had fallen
from 10.000 to 7000. The only high leucocyte-count in this
group of cases was 25,000. This patient was seen thirty-six
hours after the beginning of the attack, and clinically the
attack seemed to be subsiding ; but on account of the high
leucocytosis it was considered best to operate. In this case the
exudate about the thickened appendix was very excessive, and
it is a question whether, if operation had been delayed, an
abscess would not have developed.
The following two cases are reported in detail, the first be-
cause the patient was observed in the hospital from the begin-
ning, and represents the typical rise in the leucocytes from 8000
to 18,000 in thirty-six hours, associated with an acute diffuse
appendicitis. It cannot be stated in this case whether the
patient would not have recovered from this attack, but the rise
in the leucocytes was a distinct aid in the early recognition of
the disease, which was associated with but slight local symp-
toms.
The second case is reported in detail because it represents the
rare exception of a low and falling leucocytosis associated with
a distinct increase in the local symptoms, in which case the
operation was indicated chiefly on account of the increasing
local signs, although a careful observation indicated a falling
and a low leucocytosis.
Case I. — The patient, a girl, aged seven years, was admitted to the
hospital with a rather indefinite history of previous attacks of pain and
the history of pin-worms in the stools. When first admitted and ob-
served for seven days there were no symptoms. Suddenly, one night>
she began to complain of abdominal colic, which, in a few hours,
localized itself in the right iliac fossa ; in six hours the leucocytes were
8000; ten hours, 11,000; twenty-four hours, 17,000; thirty-six hours,
18,000. During this time the temperature rose from 98° to 100° ; no
nausea or vomiting. The local symptoms consisted only of but slight
muscle spasm and tenderness in the right iliac fossa. The slight local
BLOOD EXAMINATIONS AND SURGICAL DIAGNOSIS. I3I
abdominal symptoms, combined with the quite high leucocytosis, were
considered sufficient to indicate an early operation. The appendix
was free, but thickened by diffuse inflimmation ; the lumen of the
appendix was filled with small pin-worms.
Case II. — A colored man, aged about twenty years, entered the
hospital with a history of diarrhoea and colic of one week's duration, and
of local symptoms ; pain in the right iliac fossa, suggesting appendicitis
of twenty-four hours' duration. The first examination, temperature
104.2°; pulse, 99; respiration, 30. The patient's expression was one
of stupor; tongue coated, but moist; leucocytes, 10,000. The abdom-
inal symptoms were so slight that the possibility of typhoid fever was
considered, and a Widal test made, which was suggestive but not posi-
tive. I saw the patient four hours later. At this time leucocytes had
fallen to 7000, and the temperature to 102°; but on examination the
tenderness and muscle spasm in the right iliac. fossa had slightly in-
creased, and there was a distinct area of dulness in the right flank,
which suggested encapsulated fluid. At the operation a diffusely
thickened and inflamed appendix was found covered with a little fresh
exudate, and there was some free cloudy sterile fluid in the abdominal
cavity. The chief collection was retrocsecal where the appendix was
situated. After the operation the patient continued to have intermit-
tent fever for a week, the cause of which we could not make out ; there
were no malarial organisms; the Widal reaction was not positive, and
there was no leucocytosis. He made an uninterrupted recovery.
Gangrenous Appendicitis. Operation. Recovery. In this group
of cases, as a rule, the leucocytosis is higher and rises more
rapidly, and in three instances it has been of the greatest im-
portance in the early recognition of a grave inflammatory con-
dition of the appendix, which without doubt would have led to
general peritonitis and death if early operation had not been
instituted. In one case the rapid rise in the leucocytes was
practically the only clinical evidence of a grave abdominal con-
dition. The patient, a boy, suffered from an attack of pain and
nausea, and vomiting followed a few hours after taking a good
deal of indigestible food. When the stomach relieved itself
there was no further pain and no further abdominal symptoms.
After twenty-four hours the leucocytes were 17,000. A leuco-
132 BLOODGOOD,
cytosis of 17,000 in a patient a number of hours after taking
food would make one suspicious of an inflammatory lesion. In
thirty hours the leucocytes were 17,000, and in thirty-six hours
35,000. The highest temperature was 100°. There were prac-
tically no abdominal symptoms, except the history of a short
attack of colic and vomiting following indigestible food. Be-
cause of this rapid rise and the high leucocyte-count (35,000),
it was considered safer to explore the abdomen. A gangrenous
appendix with beginning purulent pelvic peritonitis was found.
A second and almost similar case was observed when the leu-
cocytes rose from 13,000 to 24,000 in twenty hours after
the beginning of the first colicky pain, the first count being
fourteen hours after the beginning of the pain. In this case
there were in addition marked clinical signs of appendicitis.
In a third case, with very slight local signs, the leucocytes
rose rapidly from 13.000 to 23,000 in twenty hours (first count
sixteen hours).
These three cases of gangrenous appendicitis I report in de-
tail because they demonstrate the great diagnostic importance
of the leucocyte-count.
Case I. — Observed by Dr. Thomas R. Brown, in this city, communi-
cated to me personally, is perhaps the most important. The patient,
a boy, aged eleven years, indulged freely one Saturday night, about 8
o'clock, in strawberry ice cream and soda-water ; at 4 o'clock the next
morning he was awakened with severe epigastric colic, nausea, and vomit-
ing. The patient was seen by Dr. Brown at 8 a.m. (four hours); tem-
perature 98°; pulse, 76. He was given a Seidlitz powder and powders of
subnitrate of bismuth. The abdominal examination was negative. He
was seen again at 10 a.m. (six hours), no change in the symptoms; no
nausea or vomiting. At 6 p. m. (twelve hours) the temperature was
98.8°; pulse, 86. There had been a stool ; the urine was voided without
pain ; he was apparently very comfortable, and complained of no pain ;
abdominal palpation was negative ; he looked, however, a little lan-
guid. There was nothing in the clinical picture to suggest that the
condition was anything more than that to be explained by indigestion.
On Monday morning at 8 o'clock (twenty-eight hours after the attack of
colic) his temperature was 99 4° ; pulse, 95. He had passed a com-
BLOOD EXAMINATIONS AND SURGICAL DIAGNOSIS. I33
fortable night; no nausea or vomiting; no abdominal symptoms ; but
he looked a little more depressed. The leucocyte-count at this time
was 17,000. (A leucocytosis twenty-eight hours after an attack of ab-
dominal colic in a patient taking practically no food is an indication
of some inflammatory condition.) At 11 o'clock the leucocyte-count
was 17,500; temperature, 100°; pulse, 100; but no abdominal signs.
At 4 o'clock (thirty-six hours after the beginning of the colic) the leu-
cocyte-count was 35,000; temperature, 100.6°; pulse, 100. For the
first time in the right iliac fossa there seemed to be a little swelling;
no marked muscle spasm or tenderness. He did not complain of pain
when he voided urine. This rapid and high rise in leucocytes, even
without abdominal sji^mptoms, but following abdominal colic, was con-
sidered by Dr. Brown, his physician, and Dr. Finney, the consulting
surgeon, a sufficient indication for exploration of the abdomen. On
opening the abdomen, an appendix, eight inches in length and extend-
ing into the pelvis, was found. The appendix was gangrenous for at
least two-thirds of its length, and perforated at its tip ; no adhesion,
and no localization. The pelvis was filled with cloudy fluid ; the in-
testines in the pelvis and right iliac fossa were injected, covered with
a little fibrous exudate and cloudy fluid. Cultures were not taken.
The patient recovered.
In this case the rise in leucocytes was practically the only
indication for operation. There were no previous attacks of
appendicitis, and the only clinical manifestation pointing to the
appendix was the onset of the abdominal colic associated with
nausea and vomiting.
Case II., recently observed by Dr. Mitchell and myself, resembles
Dr. Brown's observation in the rapid rise in the leucocytes, but was
associated in this instance with distinct abdominal symptoms. The
patient, a boy, aged eighteen years, who also filled his stomach one
Saturday night with indigestible food, experienced, about six hours
later, intense abdominal colic, which was worse on the right side, fol-
lowed in four hours by excessive nausea and vomiting. The abdominal
colic continued all night, and when he voided urine it gave him some
pain. He walked to the hospital, and was first examined about i p.m.
Temperature, 101°; leucocytes, 13,000. Both recti muscles were held
tense, but the muscle rigidity was more marked on the right side. The
clinical picture at this time was sufficient, without the leucocyte-count,
134 BLOODGOOD,
to make a diagnosis of pelvic appendicitis. His parents were sent for
at once, but refused operation until 6 p. m., so that he was not operated
on until twenty hours after the beginning of the attack. He was first
seen at fourteen hours. At fifteen hours the temperature was 102°;
pulse, 112; respiration, 28; leucocytes, 15,600. In sixteen hours,
leucocytes, 16,000. In eighteen hours, temperature, 104°; pulse, 112;
respiration, 28; leucocytes, 19,000. In twenty hours, temperature,
103.4°; pulse, 116; respiration, 20; leucocytes, 24,800. There had
been no nausea or vomiting since the first attack at lo'clock the night
before. The muscle rigidity and tenderness increased. At the ope-
ration a very long appendix was found situated in the pelvis, its distal
portion being two thirds gangrenous ; no perforation. The pelvis and
the lower portion of the abdominal cavity were filled with cloudy
fluid. The intestines in the pelvis were injected. Cultures : bacilli,
but no streptococci. The patient made an uninterrupted recovery.
Case III. was observed in the hospital ; the patient, one of the hos-
pital residents, aged twenty-eight years, was taken with abdominal
colic and slight diarrhoea, a condition not uncommon with the residents
during the hot summer months. At the end of sixteen hours the tem-
perature was 101°; leucocytes, 13,000. There was no distinct muscle
spasm, but a slight area of tenderness on deep palpation at the outer
border of the right rectus muscle ; no nausea or vomiting. Also about
this time micturition gave a little pain. At the end of twenty hours
the temperature was 101.6°; leucocytes, 23,000; the patient vomited
for the first time. The patient was immediately prepared for operation,
which was performed twenty-two hours after the beginning of the attack.
The temperature just before the operation was 104.2° ; pulse, 80, and for
the first time, during the preparation for operation, muscle spasm was
noted. At the operation by Dr. Halsted the entire appendix was gan-
grenous and situated in the pelvis ; in its centre over one hard con-
cretion the wall was very thin ; the pelvis was filled with cloudy fluid
containing the bacillus coli communis. The patient recovered.
^laiU Appendicitis Distended with Pus. Operation. Recovery.
There are five cases in this group; in all the localized symp-
toms were sufficient to indicate immediate operation, due, per-
haps, to the great tension of the. thickened and inflamed
appendix, which was distended with pus, but not yet gan-
grenous. Such a condition is one of great danger, because an
i
BLOOD EXAMINATIONS AND SURGICAL DIAGNOSIS. I35
appendix distended with purulent material containing, without
much doubt, bacteria of great virulence, might perforate at any
moment and discharge into an unprotected peritoneal cavity.
Fortunately, in these five cases the operation was performed in
time. Two cases were admitted twenty-four hours after the
attack — in one the leucocytes were 15,000; in the other, 19,000.
The local signs in the patient in which the leucocyte-count was
only 15,000 was less marked, the pus in the appendix was
of smaller quantity, the walls of the appendix thickened and
under less tension. What would have happened if observed a
number of hours longer is difficult to tell. Two cases were
admitted forty-eight hours after the beginning of the attack,
one with a leucocyte-count of 17,000, with a second count in
two hours, just before the operation, of 20,000. The other of
21,000, second count of 28,000. A third case, admitted on
the second day, observed five hours, showed a rising leucocyte-
count from 18,000 to 35,000. In these three cases the clinical
picture was a marked one, and the appendix was not much thick-
ened, and under great tension. In only one of these five cases
was there a walling off of the appendix by peritoneal adhesion of
exudate, and it seems fair to infer that a perforation would have
been followed by a very virulent and perhaps fatal peritonitis.
Appendicitis. General Pei'itonitis. Operation. The correct
interpretation of the leucocyte count in this group of cases is
difficult, because in the majority of cases it is hard to estimate
the duration of the peritonitis. Observations seem to demon-
strate that in the early hours of peritonitis there is a rapid
rise in the leucocytes, which, however, soon falls. These cases
have been grouped according to the duration of the attack and
not to the approximate duration of the peritonitis. Five cases
have been observed, in each of which the beginning of the
attack was within forty-eight hours. Three cases recovered.
One operated on sixteen hours after the beginning of the attack,
with a leucocytosis of 14,000; i, twenty-four hours, with a
leucocytosis of 32,000; and i, thirty-six hours, with a leuco-
cytosis of 36,000. In these 3 cases there were distinct local
symptoms, but slight general abdominal symptoms. There
136 ^ BLOODGOOD,
was no distention of the intestine; the exudate was chiefly
purulent; in the exudate in the general peritoneal cavity only
the colon bacilli were found, and no streptococci. In i case
observed forty-eight hours after the beginning of the attack,
and operated on at once, the leucocyte-count was 25,000. The
general abdominal symptoms masked the local symptoms, the
patient was very ill, the intestines were distended, streptococci
were present, and the patient died. One patient was observed
in the hospital. Twenty hours after the beginning of slight
abdominal colic localized in the right iliac fossa, the leucocytes
were 8000; six hours later, or thirty-six hours after the begin-
ning of the attack, the leucocytes were 20,000. Clinically, the
patient was not very ill, but on account of the rise of the leuco-
cytes from 8000 to 20,000, operation was performed. The ap-
pendix was perforated and surrounded by a few drachms of puru-
lent material ; this pus was not walled off by adhesions ; the
general peritoneum was slightly injected; it appeared as if there
was beginning general peritonitis. After the operation the leuco-
cytes continued to rise for twelve hours up to 26,000; then
within the next twelve hours fell to 11,000, the patient dying,
with a clinical picture of peritonitis which was found at autopsy.
In this case the streptococci were present. In 5 cases admitted
three days after the onset of the symptoms, all showing the
clinical picture of peritonitis, the leucocyte-counts in 4 were
11,000, 1 1,000, 13,000, and 14,000. These 4 cases were fatal.
The fifth case, whose leucocyte-count was highest (17,000), re-
covered. The cultures from the peritoneal cavity in this case
showed bacillus coli communis. These counts and others not
given in this short paper seem to demonstrate that within
forty-eight hours after the beginning of an attack a very high
leucocytosis is suggestive — but not at all positive — of begin-
ning peritonitis, and that the leucocyte-count does not help us
with regard to prognosis. After the second day, in cases in
which the peritonitis has been present longer, we have never
observed a recovery with a low leucocyte-count. If the leuco-
cytosis still remains high at this period, the prognosis seems
better for the ultimate recovery after operation.
J
BLOOD EXAMINATIONS AND SURGICAL DIAGNOSIS. I37
Appendicitis. Abscess. So far, in our observations, we have
but 2 cases of abscess with leucocyte-counts observed within
forty-eight hours after the beginning of the attack. In i the
leucocytosis was 18,000, and there were distinct local signs,
although on account of the muscle spasm it was impossible to
make out a collection of pus. This patient was operated on
twenty-four hours after the beginning of the attack. A small
abscess was found about the perforated appendix, the collec-
tion of pus was well walled off, but there was beginning
peritonitis demonstrated by cloudy sterile fluid and fibrinous
exudate on the intestines about the abscess. The patient re-
covered.
The low count, ii.ooo, twenty-four hours after the onset,
is hard to explain. This patient had marked local signs of in-
flammation, but no definite tumor. At operation there was
evidence that there had been recurrent attacks, the adhesions
about the appendix were very firm, but the collection of pus
was very small.
Between two and seven days there have been 27 cases of
appendicitis, with abscess. In 6 cases the leucocyte-counts
have been between 11,000 and 12,000; the others higher, the
majority between 18,000 and 30,000. The interpretation of the
leucocytes at this stage of the disease, especially between the
third and seventh day, is a difficult one. A high leucocytosis
after the second day of the disease, in the majority of instances,
is an indication of gangrene, pus in the appendix, abscess, or
peritonitis. A low leucocytosis has been associated with an
acute attack, getting well or completely over, but in a few
instances it has been associated with abscess and peritonitis. In
these 6 cases of abscess, with leucocyte-counts between 11,000
and 12,000, 4 were distinctly getting well, the abscess well
walled off"; in 2 the patients were very ill, and there was evi-
dence of beginning peritonitis ; i died.
The interpretation of the leucocytosis in the cases of appen-
dicular abscess between one week and one month has already
been discussed with the group of cases of chronic and subacute
appendicitis.
138 BLOODGOOD,
Conclusions in Regard to the Interpretation of the White Blood-
count in Appendicitis. Although there are exceptions to the
rule, a rising leucocytosis is an indication for an operation. In
the majority of instances if the leucocytes reach 18,000 before
forty-eight hours, it has been an indication of an advanced
pathological lesion. For example, excessive exudate with a
diffuse appendicitis, gangrene, or an appendix distended with
pus, abscess, or beginning peritonitis. When the leucocytes
have been below 18,000, or when counted a number of times,
have fallen in number, the patients have recovered without
operation. With a fall in the leucocytes there has been asso-
ciated a rapid cessation of the local symptoms, or, if operated
on, the appendix has been the seat of but slight diffuse inflam-
mation.
Observed later in the attack, especially after the fourth day,
a high leucocytosis has usually been associated with localized
abscess or peritonitis. It is to be remembered, however, that it
is possible to have an abscess with a low leucocyte-count. Out
of the 56 cases of appendicitis with abscess, 14 have had a leuco-
cyte-count between 6000 and 12,000; the remainder have been
higher, the majority over 20,000 ; the usual count is between
20,000 and 25,000, one count 30,000, one 60,000.
It is also to be remembered that with peritonitis there may
be a very low leucocyte-count. This, so far in our observations,
has been associated with an extreme septic condition of the
patient, and in every case death has followed. These low leu-
cocyte-counts have been observed in patients admitted to the
hospital three days or longer after the beginning of the attack;
so it is difficult to ascertain the exact duration of the peritonitis.
Observations are sufficient to indicate that in the majority of
instances beginning peritonitis is associated with the rise in the
leucocytes, which, however, rapidly falls as the patient becomes
more septic.
In a general way we may feel that a patient admitted with
symptoms of peritonitis, with a high leucocyte-count, has better
chance for recovery. The leucocyte-count simply indicates,
however, a short duration of the peritonitis. The positive
k
BLOOD EXAMINATIONS AND SUKGICAL DIAGNOSIS. 1 39
prognosis depends more upon the bacteriological findings than
upon the leucocytosis. So far in our observations in the 4
cases which recovered, the cultures demonstrated the presence
of colon bacilli and other bacilli, but no streptococci.
Before more definite conclusions can be made in regard to
the interpretation of leucocytosis in appendicitis we must
have more observations, especially observations of cases
from the beginning of the attack, where we have a number
of counts. There are sufificient observations, however, to
make a careful surgeon insist upon a blood-count in every
case of acute abdominal lesion, and during the first forty-eight
hours to have counts made every four or six hours. A rapid
rise in the leucocytes, especially above 18,000, should, in my
opinion, be a sufficient indication for exploration, even in those
cases in which the local symptoms are very slight. In the few
exceptions in which the local symptoms are sufficiently distinct
to indicate an operation, a low leucocytosis should not influence
as to delay operation.
Leucocytosis in Intestinal Obstruction. Dr. Harvey Gushing, I
think, was the first in this country to call attention to the leuco-
cytosis associated with intestinal obstruction. I referred to this
in Johns Hopkins Hospital Reports, vol. vii., 1898, p. 332, in rela-
tion to leucocytosis in strangulated hernia. Since Cushing's first
count in August, 1898, the leucocytes have been estimated in
almost every case of intestinal obstruction, and in this group
of cases the increase in the number of white cells associated
even with very slight symptoms of intestinal obstruction, has
been found to be of great value in the early recognition of the
obstruction, frequently before the clinical signs were positive.
We have a large group of cases which have demonstrated that
within twelve hours after the beginning of the obstruction the
leucocyte-count may rise to 20,000. Within the first twelve to
twenty-four hours a few observations would demonstrate that if
the leucocyte-count rises above 25,000 or 30,000 the probabili-
ties are that one will find gangrene of the obstructed loop or
beginning peritonitis. If observed on the second or third
day after the beginning of the symptoms it is difficult to
140 BLOODGOOD,
make a differential diagnosis with regard to gangrene or
peritonitis. After the third day, in cases in which there is
no gangrene and no peritonitis, or in which the auto-intoxi-
cation is not yet very grave, the leucocytes still remain high,
15,000 to 23,000, according to the degree of obstruction : com-
plete, higher; partial, lower. In the presence of gangrene,
peritonitis, or grave auto-infection, the leucocytes begin to fall.
If the patient is admitted after the third or fourth day with a
history of intestinal obstruction, and still has a high leucocyte-
count, the prognosis is good for operation. If the count is low,
and especially if it is below 10,000, the probabilities are that
you will find at operation extensive gangrene or peritonitis ; or
the patient will be so depressed by the auto-intoxication that
reaction does not follow relief of the obstruction.
In 5 cases of strangulated hernia admitted within twelve hours
after the rupture had become irreducible, the leucocyte-counts
were 10,000, 15,000, 18,000, and in 2 cases 20,000. In all of
these cases the sac contained congested intestine. All the cases
recovered after operation. In the one in which the leucocytosis
was 20,000 we were able to reduce the rupture with ice bags, the
leucocytes falling in three hours to 18.000, and in twenty-four
hours to 12,000. In i case the patient left home with an irre-
ducible hernia of some hours' duration; but during the journey
of some fourteen hours on a railroad train the rupture became
reduced, and on admission the leucocyte-count was but 6000,
which seemed to exclude the possibility of reduction en bloc of
the rupture. The patient recovered, and some days later was
operated on for the reducible hernia.
An observation of my own demonstrates the importance of
even a slight rise in the leucocytes as an aid to early recognition
of obstruction. The patient had previously been operated on in
the hospital for acute appendicitis with abscess, and the wound
had been drained. This clinical history, of course, pointed to
the possibility of obstruction from adhesions. Some four months
after this operation he came to the hospital complaining of ab-
dominal pain of six hours' duration in the region of the scar.
There had been no nausea or vomiting, and abdominal examina-
BLOOD EXAMINATIONS AND SURGICAL DIAGNOSIS. I4I
tion was negative. The pain, however, was quite severe, and
was sHghtly remittent, as if coincident with peristaltic action,
although such intestinal movements could not be made out
during a long and careful examination. The leucocyte-count in
four hours rose to 12,000. There was no fever, and the patient
had not taken any food.
In view of the history and rise of the leucocytes an explora-
tory operation was done. It was found that the omentum and
caecum were adherent to the old wound, and to the Ccijcum was
an adherent knuckle of small intestine, producing a partial ob-
struction. The ileum from this point of obstruction for a dis-
tance of one foot was collapsed; in the other direction slightly
distended. The operation required some time in order to sep-
arate all the adhesions, and it was fortunate that an early explo-
ration was done, when the patient was in sUch a good condition
that prolonged anaesthesia was not contraindicated.
The Leucocyte-counts in Cholecystitis.
Acute Cholecystitis. In 7 cases the leucocyte-counts have varied
from 20,000 to 26,000. Two cases admitted at the end of the
attack, with no symptoms, had leucocyte-counts of 8000. The
rise in the leucocytes associated with symptoms of acute chole-
cystitis does not seem to demand the same imperative early
operation as similar counts associated with symptoms of appen-
dicitis, because here the danger of peritonitis or abscess is a
very distant one. We have observed 2 cases from the very
onset in the hospital. One case was of special interest because
the cholecystitis occurred during convalescence from typhoid
fever.
The patient, a woman, aged forty-nine years, was admitted to the
medical side, apparently at about the tenth day of typhoid fever ; the
leucocyte count was 6000. During the forty-two days she had a more
or less uninterrupted typical typhoid attack, with no rise in leucocytes.
On this day (the forty-second), at 4 o'clock in the morning, the tem-
perature, which had been normal for some days, rose to 101.7^, and
in tour hours to 105.2°. The patient complained of pain in the ab-
domen and region of the gall-bladder. In this area there was distinct
142 BLOODGOOD,
muscle spasm, but on account of muscle spasm no tumor could be
made out. Respiration, 56; pulse, 128; the leucocytes had risen to
16,500; in three hours to 22,000. The operation was performed at
this time, five hours after the beginning of the attack ; the gall bladder
contained gallstones and slightly purulent bile ; cultures, the bacilli
coli communis.
The second case was rather a feeble man, aged sixty-five years, who
on November 3, 1899, under ether anaesthesia, had been operated
on for a very huge lipoma of the thigh ; following the operation
pneumonia associated with a high leucocytosis. For some days the
temperature had been normal, with no leucocytosis. On November
15th, in the morning, he complained of abdominal pain in the gall-
bladder region, slight nausea, and vomiting. Examination of the
abdomen was negative. This attack of pain lasted a few hours, and
then disappeared ; temperature, 100° ; pulse, 99. During the afternoon
he had slight attacks of pain. The next morning, twenty-four hours after
the first gall-bladder colic, associated with pain, the temperature rose
to 102°, in a few hours to 103° ; leucocytes, 13,000. In the gall-
bladder area there was distinct tenderness and muscle spasm, and on
deep palpation one felt a tumor descending on inspiration. The
leucocytes rose from 13,000 to 22,000 in six hours. There were no
signs of pneumonia or of malaria ; clinically the picture was that of
acute cholecystitis. The operation was performed under cocaine
anaesthesia, the gall bladder was distended and contained purulent
material and a few gallstones. The cultures showed bacilli coli com-
munis and staphylococcus pyogenes aureus. The patient recovered.
J
BLOOD EXAMINATIONS AND SURGICAL DIAGNOSIS. I43
DISCUSSION.
Dr. B. Farcjuhar Curtis, of New York, in discussing these papers,
said : I am surprised to learn by the reports from Boston of the ab-
sence of leucocytosis after operations done under ether and local anaes-
thesia. At St. Luke's Hospital we have made a series of these obser-
vations, and while it is true they have been done by the resident staff,
yet they have been very consistent in their results. I feel sure they
are not lacking in accuracy, and in the majority of cases we have
found a marked leucocytosis which has no reference to the length of
the anaesthesia, to the amount of the drug, or to the severity of the
operation. Lately, I have been interested in three or four operations
done under intraspinal anaesthesia, and in those operations leucocyte-
counts were made at intervals of from one to two hours. A progres-
sive increase, was found corresponding to that found under general
anaesthesia. In the latter case we have both the effect of the drug
itself upon the blood and of the other inhalation upon the lung, while
in the local anaesthesia we have simply the effect of the cocaine and
the injection of fluid into the spinal canal, but the increase in leuco-
cytes was noted in every case for at least five hours. It then remained
stationary, sometimes reaching as high as 18,000, and came down
slowly during the next forty-eight hours. There was no infection in
any of these cases, but in one of them, although a small part of the
flap sloughed, the leucocyte-count did not remain high. I believe
that operative leucocytosis may be assumed to be a fixed factor, and it
is therefore impossible to use the leucocyte-count in determining the
presence or absence of infection in the first two days after operation.
I feel that the gentleman from Baltimore ranks the value of the leuco-
cyte-count too high. I think it is of equal value with the temperature
and pulse, but is not higher. We meet too many contradictory cases.
I recall the case of a man, aged about forty-five years, who was ad-
mitted to my wards at night with symptoms of appendicitis. The
leucocyte-count was only 7500, although the temperature was high
(102°), and I postponed operation until the next day. By that time
the temperature had dropped to normal, and the tenderness, which
was very acute the night before, had considerably lessened, but four
days later I obtained consent to do an exploratory operation. A
144 BLOOD EXAMINATIONS AND SURGICAL DIAGNOSIS.
movable mass about the size of the end of the thumb was found in
the region of the appendix, and there was a limited collection of
pus, i.e., a retroperitoneal abscess. These conditions were difficult
of explanation, as there was an absence of leucocytosis, although the
patient was not thoroughly septic, and, although the collection was
walled off, the man's high temperature showed absorption of toxins.
FRACTURES OF THE PELVIS FROM VIOLENCE EX-
ERTED THROUGH THE LONG AXIS OF THE
FEMURS, BEING A COMPARATIVE STUDY
OF THE RELATIVE STRENGTH OF THE
NECK OF THE FEMUR AND THAT
OF THE PELVIS WHEN THE
VIOLENCE IS TRANSMITTED
THROUGH THE LONG
AXIS OF THE
FORMER.
By OSCAR H. ALLIS, M.D.,
PHILADELPHIA.
Were a person to be caught between two cars, or crushed
between falling rocks, a fracture of the pelvis would be attrib-
uted to direct violence. But when one reads of a bale of cotton
falling upon a laborer's back, producing fatal injuries, and at the
autopsy a fracture of the pelvis, with rupture of the bladder, is
found, the evidence of direct violence is perfectly clear ; but just
how a soft, vulnerating body, like a bale of cotton, could fracture
the pelvis is not clear, unless one imagine that the victim's body,
driven downward by the weight of the cotton, struck upon some
hard, irregular substance, thus producing a crush similar to that
between two cars.
Plausible as such an explanation of the fracture may seem,
and possibly correct in some instances, there is another which
seems much more plausible, viz. : that the blow from the bale of
cotton, striking the man on his back, forced him down upon his
knees, and as soon as the knees struck the ground, and could
go no further, the unspent force, acting upon the pelvis, drove
Am Surg lo
146 ALL IS,
the socket against the head of the femur, and thus the pelvic
arch received a strain before which it yielded. This explana-
tion is far from being a theoretical one. I have so frequently
fractured the pelvis by forcing the head of the femur against the
sockets that I am inclined to think that fractures of the pelvis
from violence through the long axes of the femurs is far more
frequent than fractures from direct pressure.
In my earlier experimental work upon the cadaver I was
inclined to the belief that dislocations of the femur from force
exerted through the long axis of that bone were infrequent, and
when such a force assumed sufficient magnitude a fracture of
the neck of the femur or of the rim of the acetabulum would
be the more probable result. A wider experience has compelled
me to modify this belief, and to assert that force exerted along
the long axis of the femur will (i) frequently fracture the pelvis,
(2) occasionally produce a dislocation backward, but (3) 7iot in
a single ijtstance has such violence produced a fracture of the
neck of the femur.
The reader will please not misunderstand the conditions under
which this statement is made. Every hospital surgeon knows
the frequency of fracture of the neck of the femur, even in
middle life, from violence, while the ease with which the femoral
neck is broken in the aged is universally known. The point I
wish to make and emphasize is that when fracture of the neck
of the femur occurs it does not take place from violence ex-
erted through the long axis of the shaft, but rather from vio-
lence through a blow upon the trochanter or, still more prob-
ably, through a twist of the femur.
I am well aware that violence applied cautiously and deliber-
ately by means of a long lever cannot be expected to produce
the identical injuries that would result from the momentum of
a falling body or a fall from a runaway horse, and hence my
deductions cannot be regarded as universally applicable. Be
this as it may, the result of violence applied cautiously and sys-
tematically has led me to note the points where violence under
given laws will explode, and when the evidence is clear that
violence has been exerted upon the knees through a fall upon
FRACTURES OF THE PELVIS. I47
them, and that the force has been carried through the long axes
of the femurs to the pelvis, I would be very far from assuring
my patient that there was no fracture simply because I could
find none in any part of the femur.
My experiments have led me to consider the surroundings of
the accident. Let me, for example, allude to persons knocked
down by a rapidly moving carriage. Death has followed many
such accidents, and at the autopsy the pathologist has looked
in vain for the track of the wheel to account for fracture of the
pelvis. My experiments, in which the pelvis has been invari-
ably fastened to a. hard platik and the violence exerted upon the
knees, have resulted in injuries so closely allied to those from
run-over injuries that I am persuaded that one may entertain a
serious error if he attributes the fractures of the pelvis invari-
able to the wheel of a carriage.
In my experimental work I have not arrived at the degree of
exactness that enables me to predict what the result of violence
to a certain part will be. I have applied force to the knee when
semiflexed, the pelvis being fixed and the foot resting on an
immovable block, and in certain instances there has been frac-
ture of the tibia near the knee, depression of the articular sur-
face of the tibia and femur, dislocation of the tibia backward,
fracture of the acetabulum and fracture of the rami of the
ischium and pubes, but in no instance have I fractured the
neck of the femur.
When I have exerted the force upon the femur at right
angles to the pelvis I have produced a dislocation backward —
fracture of the acetabulum or fracture of the rami of pubes and
ischium ; but in no instance have I fractured the neck of the
femur.
The following demonstrations were then made:
A cadaver was fixed upon the table and the lever placed over
the semiflexed knee. The pressure was downward, resulting in
fracture of the tibia and fibula above the ankle, but not injuring
the neck of the femur.
The lever was placed above the knee flexed to right angle.
Fracture of the acetabulum and ramus of the pubes resulted.
148 FRACTURES OF THE PELVIS.
The femur, with flesh removed, was laid upon the table so
that the head supported one end and the condyles the other.
The shaft was two or three inches above the surface of the table.
The lever was placed over the middle of the shaft. The elas-
ticity of the femur was beautifully demonstrated. It finally
broke, but not at the neck.
The femur, with flesh removed, was placed perpendicularly
upon a pine slab, and force brought to bear upon the condyloid
end. The head was driven deeply into the slab and the shaft
finally broken, but not at the neck.
ON PANCREATITIS.
By a. W. mayo ROBSON, F.R.C.S.,
LEEDS, ENGLAND,
SENIOR SURGEON TO THE GENERAL INFIRMARY AT LEEDS ; EMERITUS PROFESSOR
OF SURGERY IN THE YORKSHIRE COLLEGE OF THE VICTORIA UNIVERSITY.
Mr. President: I must first thank you, sir, and the Council
for the great honor done me in inviting me to come to Balti-
more and take part in the proceedings of the American Surgi-
cal Association, which I consider also a privilege and a pleasure.
Having expressed my views on chronic pancreatitis and its
relation to cholelithiasis at the London Polyclinic in June, 1900,
and having been invited to open the discussion on Diseases of
the Pancreas " at the International Medical Congress at Paris in
August last, I almost regretted having promised to give this paper
before the American Surgical Association, lest it might appear
as if I were simply giving a rechauffe of my views, but it is as-
tonishing how much has recently been written on the subject.
Not only have my observations been confirmed by numerous
workers, who have expressed their views in writing, but from
conversations that I have had with surgeons who are frequently
operating on the abdomen ; nearly all have had one or more
cases which they had diagnosed as gallstones in the common
duct, for which they had operated, but finding a tumor of the
head of the pancreas, they had simply drained the gall-bladder
and given a bad prognosis, thinking the disease to be cancer;
and only on the complete recovery of the patients had wonder
been excited and some other explanation sought for. More-
over, my own experience has been increased, and as the result*
of further observations I have views to advance which will,
I hope, produce a useful discussion.
150 ROBSON,
I do not propose to weary the Association with a recital of
many cases, a number of which have been reported and can
easily be referred to if wanted ; but I should like to give what
time I have to a brief consideration of the relation between fat
necrosis and hemorrhage, to the relation of gallstones and pan-
creatic diseases, and to the treatment of pancreatitis generally.
It is a curious fact that, although surgeons have been remov-
ing gallstones from the common duct for a little over ten years —
z". (?., since Courvoisier's first successful choledochotomy in 1890,
and that although the subject of jaundice, dependent on obstructed
common duct, received great attention from physicians many
years ago, yet until comparatively recently it never seemed to
dawn on the minds of clinical observers that whatever obstructs
the common bile duct at its lower end must also of necessity
lead to an obstruction in the pancreatic duct ; and although,
since the description of the disease by Charcot as intermittent
hepatic fever, infective, and suppurative cholangitis have been
well recognized by pathologists, yet infective and suppurative
catarrh of the pancreatic ducts have even yet received no place
in the medical text-books, which means in reality that all dis-
eases of the pancreas, except those producing gross organic
changes, such as cancer, acute pancreatitis, cysts, and calculi,
have been practically ignored ; yet we know, both by post-mor-
tem observation and by surgical experience, that under similar
conditions the pancreatic ducts participate in the same inflam-
matory processes as the bile ducts.
When the common bile duct is obstructed the objective sign
of jaundice at once demonstrates the fact ; hitherto, however,
no pathognomonic sign has been discovered which will show
conclusively that the pancreatic ducts are occluded, unless it be
the extremely rapid loss of weight. As is now well known, the
presence of fat necrosis does afford some clue and a very im-
portant one, only hitherto discovered, however, when the abdo-
men is opened ; but even for fat necrosis to take place, there
must probably have been some escape of the fat-splitting fer-
ment from the gland, and therefore the affection of the pancreas
must be somewhat advanced before the sign is evident. Glyco-
ON PANCREATITIS. I5I
suria, lipuria, and fat in the stools occur too seldom to be of
much use in the diagnosis of pancreatic disease, though when
present they are of great diagnostic importance. I think that
physiological chemistry may, perhaps, help us in the diagnosis,
and though our observations are not by any means yet complete,
I hope that some researches, at present being conducted on cases
under my care, by my friend, Mr. P. J. Cammidge, pathologist
to the West Riding County Council, may prove of practical use,
and I have some grounds for hope that by an examination of
the urine alone, or of the urine, the blood, and the feces, that
we may have some assistance in the diagnosis of these difficult
cases.
The pancreas is a racemose gland well supplied with blood,
and unlike the parotid, the lobules of which are well supported
by fibrous partitions, its tissues are comparatively soft in con-
sistence and easily bruised, so that although it is placed in the
most favorable position for protection from direct injury, yet a
slight injury takes more effect on it than on many other firmer
organs, and we have experience of pancreatitis resulting from
blows in the epigastrium apparently trifling in character, as in a
case that I saw several years ago where a butler slipped and fell
forward against a knife-board projecting from the end of the
table at which he was working. The blow was comparatively
slight, and the man did not even fall to the ground ; but acute,
so-called hemorrhagic pancreatitis followed, and the patient
died. An exploration for peritonitis, followed by an autopsy,
revealed the true cause of death.
Probably slight injury to the pancreas often occurs in abdom-
inal operations for gallstones in the common duct, when it is
sometimes necessary to manipulate and rather forcibly draw the
parts in the neighborhood of the pancreas forward in order to
view the common duct when sutures are applied.
Such a case has indeed been related recently.
When it is borne in mind that the pancreatic duct opens along
with the common bile duct into the second part of the duode-
num, a channel usually containing septic organisms, especially
when it is the seat of catarrh, to which it is especially liable, it
152 ROBSON,
is not a matter for surprise that pancreatitis should be met with,
but rather that it should not occur more frequently.
As in the liver, we may have simple, infective, and suppura-
tive catarrh of the excretory ducts, as well as inflammation of
the interlobular tissues ; so in the pancreas we undoubtedly have
similar diseases, which are only awaiting our recognition during
life by greater diagnostic skill. As bearing on this, the pathol-
ogist of a large hospital has told me that in cases of obstruction
of the common duct by gallstones, he has noticed that pus can
usually be expressed from Wirsung's duct, and this has been
confirmed by others.
I feel sure that, as our means of diagnosis become more per-
fected, diseases of the pancreas, both functional and organic,
will be more frequently recognized and awarded their deserved
positions in medicine.
Since my countryman, Dr. Walker, of Peterborough, showed
that the absence of the pancreatic secretion from the intestine,
even though bile were present in the intestinal canal, led to pale-
colored motions, very little attention has been paid to this sign,
although much has been written about the presence of sugar in
the urine in pancreatic disease ; yet, glycosuria is in my expe-
rience a very rare phenomenon in this relationship, and, in fact,
it only occurs when there is great destruction of pancreatic
tissues, as in extensive cirrhosis or in extensive malignant dis-
ease.
Fat in the stools is more common, but not by any means uni-
versal, and lipuria is still more uncommon.
I have seen cases of discomfort, with some swelling at the
epigastrium, associated with dyspepsia and ague-like attacks,
but without jaundice, or with only very slight jaundice, which I
thought might be explained on the hypothesis of infective in-
flammation of the pancreatic duct, the cases having cleared up
under general treatment. I have also seen the same symptoms
associated with more pain, irregular fever, more marked swelling
and tenderness over the pancreas, and discharge of pus by the
bowel from time to time, but without any collection sufficiently
large to form a distinct abscess. I related a case like this in
ONPANCREATITIS. 153
the lecture previously referred to, but the recovery of the patient
made the absolute certainty of the diagnosis doubtful, though
an examination under an anresthetic enabled a swelling of the
pancreas to be felt, and this was confirmed by palpation of the
abdomen at a later stage, when tenderness was less marked.
I thought this case was probably a subacute pancreatitis as-
sociated with suppurative catarrh of the pancreatic ducts anal-
ogous to suppurative cholangitis.
The essential and immediate cause of the various forms of
pancreatitis is bacterial infection, this having been positively
proved both clinically in the human subject and experimentally
in the lower animals, but as in inflammatory affections of the
liver and bile ducts we look for extrinsic causes, so in pancreatic
diseases we find biliary and pancreatic lithiasis, injury, gastro-
duodenal catarrh, ulcer, and cancer of the stomach, pylorus, or
duodenum, and zymotic diseases, such as typhoid fever and in-
fluenza, to be determining factors, though in some cases pancre-
atitis has come on suddenly in persons in robust health and the
determining cause has been beyond recognition.
Though the infection may arise from the blood, as in pyaemia,
or by direct extension from the neighboring tissues, as in ulcer
of the stomach, yet the most usual channel is through the duct,
as in the cases arising from gallstones in the common duct and
from gastro-duodenal catarrh that I related in my lecture.
The association of gallstones with chronic pancreatitis was
absolutely forced on my mind by the frequency with which I
found inflammatory enlargement of the head of the pancreas
when operating for gallstones in the common duct, the first
instance of the kind having been observed by me in 1892 in a
case on which I operated for deep jaundice, supposed to be due
to common bile-duct obstruction, but in which I found cirrhosis
of the head of the pancreas. Since that time I have operated
on a considerable number of cases (over twenty), and though
only one patient has died directly from the operation, in two
others, one a cholecystenterostomy and the other a cholecystot-
omy, death occurred within a few months, and the correctness of
the diagnosis was verified both by autopsy and by a microscopical
154 ROBSON,
section of the diseased pancreas. I am able to show the pan-
creas from the last case, and also a microscopical section of the
specimen. It is a simple matter to infer that if common duct
cholelithiasis can give rise to chronic pancreatitis, it will also be
likely to induce the subacute and acute form of the disease, and
this is, I think, now clearly proved. In the British Medical
Journal for November 14, 1896, Dr. Kennan described a case
of acute pancreatitis ending fatally on the second day in a
woman, aged thirty-eight years, and at the post-mortem exam-
ination a large number of gallstones were found in the common
duct, one being partly extruded into the duodenum.
Korte {Deutsch Chir., Stuttgart, 1898) notes that lesions of the
pancreas are frequently associated with diseases of the bile
ducts.
Lancereux {Traite des maladies des foie et des pancreas,
1898) mentions the possibility that a gallstone impacted in
the diverticulum of Vater may occlude the pancreatic duct and
produce conditions favoring the entrance of organisms into that
duct.
Dr. Opie, in a very instructive and interesting paper in the
American Journal of the Medical Sciences for January, 1901, p.
27, relates cases, one of Dr. Osier's and several from various
sources, showing the relationship between pancreatic and gall-
stone troubles.
Mr. Gilbert Barling {British Medical jfoumal^ December 22,
1900) has given several interesting cases bearing out very fully
the views expressed above.
In some of my cases gallstones were not found, but only old
and firm adhesions, with an antecedent history of paroxysmal
attacks, followed by jaundice, which afforded strong presump-
tive evidence that cholelithiasis had been present at some time ;
and it seems quite possible that temporary occlusion of the com-
mon duct with the damming back of infected secretions, or with
injury to the ducts, may set up a pancreatitis, which may itself
then cause compression of the common bile duct, and so lead to
a perpetuation of the obstructive jaundice and other troubles,
started, in the first instance, by impacted gallstones.
ON PANCREATITIS. 155
Fat Necrosis. By fat necrosis is understood a splitting up
of the fat into fatty acids and glycerin ; the latter is absorbed,
but the acids, being insoluble, remain in the cells and unite with
calcium salts, forming yellowish-white patches of various sizes
in the subperitoneal fat and in the omentum, mesentery, etc.
It was first described by Balser in 1882, but has been since in-
vestigated by Langehans, Hildebrand, Dettiner, Milisch, Wil-
liams, Flexner, Opie, and others. Experiments by Opie, who
ligatured the pancreatic ducts in the cat, go to show that wide-
spread fat necrosis may be expected to follow very rapidly.
Fat necrosis is commonly found in association with pancre-
atitis and other diseases of the pancreas, and the relationship
between the two conditions has given rise to much speculation ;
but the facts that fat necrosis is not found in all acute pancre-
atic diseases, and that it has been noted during abdominal oper-
ations for other ailments, and in autopsies where there was no
suspicion of pancreatitis, appear to show that the condition giv-
ing rise to it is not essentially a pancreatitis, as suggested by
certain authors ; though these facts do not disprove that fat
necrosis is essentially due to interference with the discharge of
pancreatic secretion, and so to an escape of pancreatic fluid into
the tissues, whence it may be taken up by the lymphatics or
bloodvessels. Flexner {Contribution to the Science of Medicine,
Johns Hopkins Press, Baltimore, 1900) and others regard the
fat necrosis as the effect of the fat-splitting ferment of the pan-
creatic fluid, which has in some way escaped from the duct into
the surrounding tissues. It is difficult at first sight to explain
the patches of fat necrosis occurring at a distance from the pan-
creas, for instance, in the pericardium, unless it be by absorption
of the ferment and its diffusion by means of the lymphatics;
though it is easy to understand, and it undoubtedly does ex-
plain the disintegration of the fatty tissues immediately sur-
rounding the pancreas and extending by continuity, first, to
adjoining and then even to distant parts in the abdomen and
thorax.
Hemorrhage in Pancreatic Diseases. It is well known that
local hemorrhages into the pancreas may occur apart from injury,
156 ROBSON,
and apart from any general hemorrhagic tendency, and that al-
though they maybe recovered from, as shown by the remains of
extravasated blood in the gland in persons dying from other dis-
eases, yet such spontaneous hemorrhages may lead to death from
collapse either immediately or after some hours. Curiously, this
may occur in persons apparently in good health and without any
premonitory signs on which a diagnosis can be based, the only
symptoms at the time being those of collapse, with dyspnoea
and feeble pulse. It is also well recognized that a hemorrhagic
condition coexists with cancer of the head of the pancreas.
Some years ago I thought this to be altogether dependent on
the cholsemia, until increased experience in operations on
deeply jaundiced subjects has taught me that there is much less
danger of serious hemorrhage in patients jaundiced from gall-
stones than in those where the jaundice depends on pancreatic
disease. In several cases of cancer of the pancreas on which I
have operated, the bleeding has been the immediate cause of
death. In one aged subject especially was this well marked,
after a cholecystotomy for the relief of jaundice. Death oc-
curred on the third day from collapse, and at the autopsy there
was found extensive effusion of blood away from the site of
operation and behind the peritoneum, extending into the loins
around the kidneys, and into the cellular tissue beneath the
diaphragm, the blood being in sufficient quantity to account for
death ; and though the bleeding had evidently arisen from the
pancreas, there was no manifest vascular lesion to account for
the hemorrhage. In another case, sent to me in 1888 by Pro-
fessor Clifford AUbutt, a cholecystotomy was followed by per-
sistent oozing of blood from the interior of the gall-bladder and
from the stitch punctures, which resisted all then known reme-
dial measures in the way of styptics, pressure, transfusion, etc.,
and proved fatal on the ninth day. In neither of these cases
was there any peritonitis or other cause than the hemorrhage to
account for death. Now, in another patient equally deeply
jaundiced, that I saw with my colleague, Dr. Churton, in 1889,
but where the disease was dependent on cancer of the common
bile duct above the entrance of the pancreatic duct, there was
ONPANCREATITIS. 157
no hemorrhage, although the patient survived several weeks,
and died from exhaustion, due to the disease and to the suppu-
rative cholangitis accompanying it. I could give many similar
comparisons, showing the difference between the behavior of the
blood in the two classes of cases.
Before operating on these cases, I now always administer
chloride of calcium in 30- to 60-grain doses, thrice daily, for
from twenty-four to forty-eight hours previous to operation, and
by enema in 6o-grain doses, thrice daily, for forty-eight hours
afterward. This is nearly always successful in correcting the
hemorrhagic tendency.
The following case illustrates, as well as any case could, how
the failure to give it after operation led to hemorrhage, and
how its administration in heroic doses apparently saved the
patient :
Cholelithiasis; deep jaundice ; chronic pancreatitis ; duodeno-chole-
dochoiomy ; hemorrhage; recovery (reported by Mr. Gough, Home
Surgeon). — Mrs. M. E. G., aged thirty-eight years, was admitted to
the Leeds General Infirmary on January 23, 1901, with the history
that she had had typhoid fever in September, 1899, and that she had
never been quite well since. Shortly afterward she began to suffer
from biliary colic, though she had never been jaundiced till six months
before admission, from which time jaundice had never left her. On
December 24, 1900, she became much worse, with very severe parox-
ysmal pain, accompanied by shivering and profuse sweats. From that
time she lost weight very rapidly, and the jaundice deepened. On
admission the liver could be felt below the ribs, and there was a dis-
tinct fulness on deep palpation in the region of the pancreas.
From January 21st to the 31st she took chloride of calcium in
20-grain doses, thrice daily.
January 31st duodeno-choledochotomy was performed. There was
very little bleeding. A stone, nearly as large as a pigeon's egg, was
removed from the ampulla of Vater, which was laid open over a direc-
tor introduced through the papilla at its opening into the duodenum.
The head of the pancreas was felt to be much enlarged and hard.
The incision into the ampulla was not sutured, but through it the
common bile duct, very much dilated, was explored by the finger.
The anterior wound in the duodenum was then sutured and the ab-
158 ROBSON,
dominal wound closed. A drainage-tube was inserted through a stab
wound in the right loin. The patient inadvertently did not have
chloride of calcium given in the nutrient enemata, as is usual in these
cases. She did well till the morning of the 2d of February, when
the nurse noticed, at 3 o'clock, that the dressings were soaked with
bright blood.
The drainage wound was exposed, but no hemorrhage was occurring
there. On examining the abdominal incision blood was seen to be
slowly oozing from it and the stitch punctures. One drachm of
chloride of calcium was at once administered by the mouth, and three
stitches were removed. The surface of the wound was then seen to
be oozing all over. It was packed with gauze soaked in tincture of
hamamelis, and a firm dressing applied. One drachm of chloride
of calcium was given again in two hours, and afterward repeated in
3ograin doses every two hours, for six hours, it being then given
thrice daily. There was no recurrence of hemorrhage, and the patient
made an uninterrupted recovery. The drainage-tube was removed on
February 4th, and she returned home within the month.
In this case Mr. Cammidge found the characteristic crystals
in the urine, and an examination of the blood showed a very
marked diminution in the blood-plates.
These arguments are brought forward to show that there is
some, as yet ill understood, relation between pancreatic disease
and serious hemorrhage; but I cannot help thinking that it is a
mistake to allow this fact to influence our views on the pathology
of inflammation by adopting permanently the name hemor-
rhagic pancreatitis in cases where there has been no bleeding,
or no more than occurs frequently in inflammation of other
parenchymatous organs, though it may be useful to retain the
name for those cases of pancreatitis associated with well-marked
interstitial hemorrhage, and in which the disruption of the
gland by the bleeding may be the direct cause of the inflam-
mation.
I have recently read a very interesting paper in the Boston
City Hospital Report for December, 1900, by Dr. F. B. Lund,
entitled *' Acute Hemorrhagic Pancreatitis and its Surgical
Treatment, with a Report of Six Cases," yet in remarking on the
ON PANCREATITIS. 159
second case, the author says : " This case is notable for the
absence of pancreatic hemorrhage."
In the fifth case there was the evacuation and drainage of a
small abscess of the pancreas, and no evidence of hemorrhage,
and in the sixth case also there was apparently no evidence
whatever of hemorrhage. The title of the paper is surely a
misnomer; yet other authors adopt the same nomenclature in
the same indefinite manner.
Dr. Flexner produced an inflammation of the pancreas as-
sociated with hemorrhage, within forty-eight hours, by inject-
ing the bacillus pyocyaneus and the B. diphtherias into the
pancreatic duct in animals {Coritributions to the Science of Medi-
cine, Baltimore, igoo, p. 743).
Hlava also produced hemorrhagic pancreatitis by injecting
the B. diphtheriae into the pancreas.
Hildebrand {Centralbl. filr Chirurgie, 1894, Band xxii. p. 297)
suggested that the hemorrhage in acute pancreatitis was due to
trypsin.
The facts concerning hemorrhage in diseases of the pancreas
and the conclusions we have come to, after carefully consider-
ing the whole subject, are :
I. That in certain diseases of the pancreas there is a general
hemorrhagic tendency which is much intensified by the pres-
ence of jaundice. 2. That hemorrhage may apparently occur
in the pancreas, unassociated with inflammation, or with jaun-
dice, or with a general hemorrhagic tendency. 3. That both
acute and chronic pancreatitis can and do frequently occur with-
out hemorrhage. 4. That some cases of pancreatitis are asso-
ciated with local hemorrhage.
From these conclusions I think, therefore, that inflammations
of the pancreas may be more conveniently and scientifically
classified, like inflammation of other organs, as acute, subacute,
and chronic ; and that there is no reason to use the term hem-
orrhagic pancreatitis, except as a variety of acute pancreatitis,
the hemorrhage being merely an accident in the course of the
disease.
It seems to me worth while considering if the glycerin set
l60 ROBSON,
free in the tissues by the fat necrosis may possibly be the real
cause of the local hemorrhagic tendency in pancreatic affections,
though our observations are not yet sufficiently far advanced to
say that this is an adequate explanation of all the cases.
While inquiring into the subject I have become acquainted
with certain very important facts bearing on the question. If
glycerin in very small amount be injected into mice it rapidly
produces haematuria (Cammidge) or haemoglobinuria, due to
destruction of the blood-corpuscles, and in certain cases in
which glycerin has been used by gynecologists for the purpose
of inducing abortion, and in others where it has been injected
along with iodoform for the treatment of tubercular disease in
the human subject, blood has also been noticed in the urine,
sometimes in large quantity.
The blood conditions about to be mentioned may possibly serve
to explain the general hemorrhagic tendency in cases of chronic
pancreatitis associated with jaundice ; but behind this there must
be some other cause not yet discovered. Can it be due to
something absorbed from the pancreas into the blood which
only acts when the absorption has been occurring over a pro-
longed period of time? This matter seems to me to be worth
attention, and it should be possible to prove or disprove it by
experimental work.
In discussing these matters with Mr. Cammidge, he suggested
that only a small amount of glycerin could obtain access to the
blood as the result of fat necrosis. When the glycerin is set
free and the fatty acids are saponified it would become oxidized,
just like any other alcohol, and the oxidation products for which
one would look would be an aldehyde ; but the tests employed
failed to demonstrate this.
In the course of these investigations, however, it was found
that if the urine were boiled for a short time with an oxidizing
agent, and then the phenyl hydrazin test performed, an abun-
dant crop of delicate yellow needles arranged in sheaves and
rosettes was produced (specimen shown).
The untreated urine gave no such result. Normal urine,
morbid urines from gout, etc., and, most important, bilious
ON PANCREATITIS. l6l
urine from patients suffering from simple catarrhal jaundice,
also gave negative results. I may say, also, that some experi-
ments performed on bile and bile salts yielded none of the
crystals.
The number of cases is too few to allow one to more than
suggest that it may prove useful as a diagnostic test in this class
of cases ; but it is also interesting to note that on one day I
operated on two patients deeply jaundiced, in one of which
there was chronic pancreatitis ; whereas in the other, although
there was a small gallstone in the common duct, there was no
manifest enlargement or disturbance of the pancreas. Both
urines were submitted to Mr. Cammidge, and, without his know-
ing the history of either case, he sent me word that the urine in
the latter case (where there was no pancreatitis) gave negative
results, so far as the crystals were concerned, and that in the
former case, just described at length, he was able to obtain
abundant crystals.
An examination of the blood has also been made in a num-
ber of cases, with a view to ascertain if any information can be
found to explain the hemorrhagic tendency. Although glycerin
may be present, Mr. Cammidge knew of no test sufficiently del-
icate to demonstrate its presence in the blood.
A histological examination of the blood showed, in two of
the cases, a very striking diminution in the number of blood-
plates as compared with the normal blood. This diminution
of the blood-plates, whatever may be its cause, may possibly
explain the general hemorrhagic tendency in these cases.
Treatment of Acute Pancreatitis. In acute infective pan-
creatitis treatment practically resolves itself into that of peri-
tonitis commencing in the superior abdominal region. The
pain at the onset is so acute as to necessitate the administration
of morphine, and the collapse will probably demand stimulants,
which, on account of the associated vomiting, may have to be
given by enema. In the early stages the symptoms are usually
so indefinite that the indications for surgical treatment are not
clear enough to warrant operation, and until the collapse has
passed off no surgical procedure would generally be justifiable.
Am Surg ii
l62 ROBSON,
The simulation of intestinal obstruction will probably lead to
efforts to secure an evacuation of the bowels and relief to the
distention.
Just as in a perforative or gangrenous appendicitis, an early
evacuation of the septic matter is necessary to recovery, so in
this equally lethal affection an early exploration from the front,
through the middle line above the umbilicus, or from behind
through the left costo-vertebral angle, is demanded, in order to
evacuate the septic material and adopt free drainage.
The after-treatment will be chiefly directed to combating
shock and keeping up the strength until the materies morbi,
both local and general, can be thrown off.
Even if no pus be founds no harm should accrue by such an
exploration, which can be made in a few minutes through a
very small incision in the middle line above the umbilicus, if
necessary, with the aid of cocaine anaesthesia. After establish-
ing the diagnosis by the anterior small incision and the intro-
duction of a finger, the posterior incision, which must be a free
vertical one in the left costo-vertebral angle, so as to permit the
insertion of the whole hand, if thought necessary, will enable
the diseased organ to be very freely examined, and, if neces-
sary, drained for the evacuation of pus and gangrenous material,
thus involving no risk to the general peritoneal cavity and little
danger of retained septic matter, as the drainage will be a de-
pendent one.
Treatment of Subacute Pancreatitis. The subacute form
of pancreatitis is more amenable to treatment, as the indications
are so much more definite, and there is more time for careful
consideration ; and though it has usually only been attacked
when an abscess has formed and is manifestly making its way
to the surface, yet there is no reason why in some cases surgi-
cal treatment should not be adopted at an earlier stage. As in
the acute condition, morphine may be required to relieve the
collapse and support the strength.
Distention, if present, may also demand attention, and may
have to be relieved by lavage of the stomach and turpentine
enemata or by the administration of calomel by the mouth.
ON PANCREATITIS. 163
Calomel is also of benefit by acting as an intestinal antiseptic;
for which purpose it may be given in small repeated doses or
in doses of five grains, followed by a saline aperient. As soon
as the constipation is relieved, diarrhcea is apt to supervene,
when salol and bismuth, with small doses of opium, may be
given.
If surgical treatment is decided on, a median incision above
the umbilicus will enable the operator to palpate the pancreas
and locate any incipient collection of pus, which, if practi-
cable, should then be evacuated by a posterior incision in the
left or right costo-vertebral angle; or if the posterior incision be
thought impracticable, the collection of pus may be aspirated and
the cavity opened and packed with gauze, which may be brought
forward through a large rubber drainage-tube, which will, in the
course of from twenty-four to forty-eight hours, establish a
track isolated from the general peritoneal cavity. In one case
I was able to do this, but the operation was undertaken at too
late a stage to be successful, and though the patient lived two
or three days afterward, the evacuation of the pus seemed to
make very little difference to the general septic condition pre-
viously existing, and death occurred on the fourth day from
increasing debility.
The method adopted had, however, been successful from the
point of view of drainage, and the track of the gauze and tube
had been isolated from the general peritoneal cavity. If a defi-
nite abscess form and approach the surface in front or in either
loin, the treatment will be that of incision and drainage, as in
the case of any other abdominal abscess. Of five cases on
which I have operated, three recovered completely, one recov-
ered from the operation, but died a few weeks later from chest
complications and debility, and the fifth case is the one just
referred to.
The strength must be maintained by careful feeding and the
administration of stimulants, and it will be necessary to keep a
sharp lookout for further collections of pus and for subphrenic
abscess or empyema, which, on recognition, will need treat-
ment.
1 64 R O B S O N ,
The following case of pancreatitis is so exceptional, both with
regard to course and treatment, that I think it is worth relating :
Chronic gastric ulcer eroding pancreas. Pancreatitis. Abscess of
pancreas bursting into stomach. Vomiting. Impending death. Pos-
terior gastro-enterostomy. Recovery. — On November 12, 1900, I was
asked by Dr. Mercer, of Bradford, to see Mr. R., who was extremely
ill and supposed to be suffering from pancreatic disease.
On arrival I found the patient, aged thirty-five years, extremely
emaciated, lying in a typhoid condition, vomiting extremely offensive
dark-colored pus and mucus mixed with blood. He was extremely
feeble and had a rapid, weak pulse and a slight icteric tinge in the
conjunctivae ; a tumor could be felt above the umbilicus, which was
tender to pressure. On distending the stomach with COj great pain
was produced, and vomiting followed. The stomach was dilated,
reaching on the left side to the level of the umbilicus.
There had been an elevated temperature for a few weeks, but this
had become subnormal after the vomiting of pus. Pain after food
and indigestion had existed for some months, during which time there
had been steady loss of flesh : but recently, especially during the
last month, the wasting had been very considerable. There was a
little sugar in the urine, with a trace of albumin, and the feces con-
tained free fat.
No medicine had done any good either for the relief of the vomit-
ing or in controlling the horrible odor, which permeated the whole
house. A diagnosis of chronic gastric iilcer of the posterior wall of
the stomach, with secondary ulcerative pancreatitis and a"bscess of the
pancreas, was made, and gastro-enterostomy proposed as the only
means likely to produce any chance of relief, but even that seemed
almost hopeless.
He was removed to a surgical home by ambulance, and the stomach
was washed out carefully by Dr. Stevens. As showing the nature
of the stomach contents, both of the attendant nurses were made sick
by the odor of the material evacuated by the tube.
On November i8th, after enveloping the patient in cotton-wool
and subcutaneously administering strychnine, posterior gastro-enter-
ostomy was performed, a bone bobbin being used. The operation was
done as quickly as possible in order to save shock. The tumor
felt before operation was found to be formed by stomach and pan-
creas firmly fixed together toward the pyloric end, but leaving the
ON PANCREATITIS. 165
dilated portion free at the cardiac end of the stomach, so that no
difficulty was found in doing a satisfactory operation, which was com-
pleted in twenty minutes. Saline subcutaneous injections and rectal
injections were given, and strychnine was freely administered, but for
two days we had a great fight with death, apparently due to poisoning
with the foul stomach contents. Hot water was freely given to induce
vomiting on the second day, as the patient could not bear the stomach-
ptube being used. This gave relief, and afterward progress to recovery
was uninterrupted. He rapidly gained strength and put on flesh, re-
turning home five weeks after operation. His friends, who had
despaired of his recovery, were astonished to find him so well. In
April he was in such good health that he married.
The treatment of chronic pancreatitis is also by abdominal
section and drainage, but in this case the drainage is indirect
and obtained by draining the gall-bladder by cholecystotomy,
cholecystenterostomy, or duodeno-choledochotoniy. The exact
line of treatment cannot be determined until the abdomen is
opened, and for this purpose I prefer, as in all my gall-bladder
operations, a vertical incision through the upper part of the
right rectus, splitting that muscle to whatever extent is neces-
sary in order to obtain a good view of the diseased region and
to afford plenty of room for manipulation.
If a mere cholecystotomy on a distended gall-bladder is neces-
sary, an incision of one or two inches will usually suflfice, but if
the gall-bladder be contracted, or if the ducts have to be attacked,
an incision of four to six inches will be required, and if the sev-
eral layers of the abdominal wall are sutured separately there is
no fear of subsequent hernia. This I can affirm by ample expe-
rience. It saves much time and much unnecessary dragging on
the parts when operating on the common duct or duodenum to
have a free incision, and there is no retractor equal to the hand
of a skilful assistant, who, with a flat sponge interposed between
the spread-out fingers of his left hand and the viscera, will at
the same time afford the operator a good view of the field of
operation, and with his right hand help in the further steps of
the operation.
If the right costal margin or the edge of the liver be obstruct-
l66 ROBSON,
ing the view, another assistant may with advantage retract it
either by digital manipulation or by means of a wide retractor
with a long handle, so that he can stand back a little and avoid
embarrassing the operator. As a matter of experience, I sel-
dom find a second assistant necessary. A sponge in the pouch
to the right of the common duct, and one pushed down over the
right kidney, helps to catch all escaping fluids and to keep the
peritoneum clean. When the ducts or the duodenum are opened,
sterilized gauze pads are employed to mop up the fluid as it
escapes, but none of these is allowed to remain even tempo-
rarily in the abdomen. When there are gallstones present they
should be removed, unless the patient is too ill to permit of the
complete operation ; but in every case drainage must be secured,
if possible by cholecystotomy as in nearly all my successful cases ;
moreover, the drainage must not be stopped before the bile
has become healthy, and not before the greater amount of bile
is being passed by the bowel, which will be certain to occur as
soon as the swollen pancreas has subsided, if the duct be other-
wise clear of obstruction.
It might be thought that cholecystenterostomy would be an
ideal operation in the treatment of these cases, but experience
says it is not ; for instance, in one of my cases the operation
brought about so much relief that a cure was being anticipated,
yet in the third month relapse occurred, and death ensued ap-
parently simply owing to closure of the new opening between
the gall-bladder and duodenum.
In one of Mr. Barling's cases {^British Medical Journal, Decem-
ber 22, 1900), where the gall-bladder was joined to the duode-
num, he states that, although the symptoms were relieved,
enlargement of the pancreas persisted.
The course and treatment of chronic interstitial pancreatitis
are exemplified in the cases related in my lecture before the Poly-
clinic in June of last year. Possibly in some of these the
manipulation of the indurated tumor may have detached calculi
impacted in the pancreatic duct, though I was unconscious of it ;
but in others, the relief of tension as the result of draining the
bile ducts by cholecystotomy or cholecystenterostomy indi-
ON PANCREATITIS. 167
rectly drained the pancreatic duct, and thus led to a subsidence
of the pancreatitis, then to an opening of the common duct by
the relief of the tension, and so to a cure of the patient. The
simulation of malignant disease of the head of the pancreas
by chronic interstitial pancreatitis would make me hesitate to
decline operation in any case of distended gall-bladder where
the patient is in a condition to bear it, or even in any case of
chronic jaundice without distention of the gall-bladder, where
the general health is deteriorating, as, though it should be rec-
ognized that if the disease be really malignant, very little good
will be done, and life may even be shortened or only prolonged
for a short time, yet if the disease prove to be chronic pancre-
atitis, a real and permanent cure may be brought about. If a
calculus be felt embedded in the head of the pancreas or im-
pacted in the pancreatic duct, it may be reached through the
second part of the duodenum by laying open the papilla and
exploring the duct, or by dividing the peritoneum, passing be-
tween the duodenum and hepatic flexure of the colon, and then
cutting through the overlying pancreas on to the concretion.
If the papilla common to the bile and pancreatic ducts be in-
cised in the duodenum, it does not require suture, and in the
cases in which I have explored the ducts by the duodenal route
there has been no serious hemorrhage ; the anterior duodenal
opening only requires closing by a mucous and a serous suture.
Drainage of the right kidney pouch for from twenty-four to
forty-eight hours is advisable, though not always necessary, and
this is best done by a stab wound at the most dependent part.
The result of treatment in this class of cases has been most
encouraging, as out of twenty-two cases operated on only one
died directly from operation, and in that case the patient's life
was only very slightly shortened, since he was reduced to the
last stage of exhaustion before a surgical operation was sought.
Of those recovering from operation, with the exception of two
who died a few months later, complete and perfect recovery en-
sued. These results contrast very markedly with the surgical
treatment of cancer of the pancreas, where nearly half the cases
operated on have died directly as the result of operation, and in
l68 ROB SON,
those who have survived life has only been prolonged for a com-
paratively short time.
Of the three following cases, two have not been previously
reported :
Chronic pancreatitis. Cholecystotomy. Cure. Mr. D., aged forty-
five years, was brought to see me March 3, 1898, the history being
that he had been well up to twelve months before, when he began to
have painful attacks at the pit of the stomach, ending in vomiting, but
not followed by jaundice until an attack on January i, 1S98, since
which time he had been deeply and continuously jaundiced. He had
also from that time onward had continued ague-like attacks, and two
days before seeing me he had had within twenty-four hours three of these
seizures, each accompanied by pain. Within a twelvemonth he had
lost 2 stone 8 pounds in weight. On examining him there was some
swelling in the gall-bladder region, but no tenderness. The liver was
a little enlarged, but the margins felt smooth. There was decided
tenderness in the middle line just above the umbilicus, and on
deep pressure the pain was considerable and an indefinite fulness
could be felt. The diagnosis of gallstones in the common duct
was made and an operation was advised. The patient was oper-
ated on at a surgical home on March 30th, when the gall-
bladder was found to be slightly distended and surrounded by adhe-
sions to the pylorus, duodenum, colon, and omentum. No gall-
stones could be discovered, but there was a well-marked swelling of
the head and the first two inches of the pancreas, which, though
nodular and irregular, was not very hard. This extended further to
the right than normal, so as to cover in the lower end of the common
bile duct. Cholecystotomy was performed. Within twenty-four hours
of the operation nearly four pints of very off'ensive bile were dis-
charged through the tube. A specimen was examined by the Clinical
Research Association, and their report was as follows: "The bile
contains both staphylococci and streptococci, but no bacillus coli
communis could be found either under the microscope or in the cul-
ture." Fearing that the disease might be malignant, and the patient
being so extremely weak and ill, I gave a poor prognosis, but in a
few days I was able to write: "The patient is progressing very
satisfactorily, though he is still profoundly weak. Bile has appeared
in the motions, so that the obstruction is evidently overcome. The
bowels have been moved naturally, and the patient is less deeply
J
ON PANCREATITIS. 169
jaundiced and looking better generally." On April 5th I was
able to report that he was taking food well and that bile was passing
freely in the motions. He had had no recurrence of the shivering
attacks. The drainage was continued for fourteen days. On the
20th he returned home. The urine was then free from bile, and the
motions were assuming a natural color ; he was taking food well,
gaining flesh, and looking better generally. I still, however, gave a
guarded prognosis, though I said that I hoped that the tumor would
prove to be inflammatory and not malignant. . From that time onward
his progress to recovery was extremely rapid. A report I had of his
condition a few months later said he was perfectly well in every
respect and that he had fully regained his lost weight.
On March 28th of this year I had a letter from Mr. D. on the third
anniversary of his operation, expressing his gratitude and saying he
was in perfect health.
Chronic pancreatitis, with abscess associated with gallstones. Chole-
cystotomy ; relief. Death four months later from exhaustion. Autopsy.
Mr. H., aged forty years, seen by me with Dr. Woods, of Batley,
on October 11, 1900. The patient was then deeply jaundiced and
extremely ill, suffering from continuous fever with exacerbations, great
debility, and extreme emaciation. A large tumor in the region of the
pancreas could then be felt as well as a distended gall-bladder. He
gave the history of failing health for nine months and a history of
gallstone attacks and painful indigestion for some time before that ;
but, although he had had frequent attacks of abdominal pain for three
or four months, the jaundice had only supervened a fortnight before
my seeing him. At the operation he was too ill to bear a prolonged
search, and there were numerous adhesions around the tumor, which
was made out to be a swelling of the pancreas ; the gall-bladder was
simply opened and drained of a quantity of muco-pus. A quantity
of pus was discharged from the drainage-tube several da)s after opera-
tion, and this was repeated on two or three occasions, as if it came
from a deeply-seated abscess. A large drainage-tube having been
used, there was a free discharge of bile and a considerable number of
gallstones were evacuated through it, thirty-three in all. Previous to
the operation the patient was suffering from shivering attacks and a
persistently elevated temperature, which subsided immediately after
drainage was eff"ected, and the temperature kept nearly normal through-
out the remainder of his illness, it being normal in the morning.
170 ROB SON
though there was usually a hectic rise each evening. He made a slow
though apparently steady recovery from the operation, and the pan-
creatic tumof diminished so rapidly that it was confidently believed
to be entirely disappearing, it being only one-third as large as at the
time of the operation. He returned home December 14th, but he
never really picked up strength, and, though there was no further ele-
vation of temperature, he gradually got weaker and died in February.
At the post-mortem examination made by Dr. Woods a tumor of
the pancreas was discovered, which was carefully examined by Mr.
Cammidge and pronounced to be a chronic inflammatory tumor, and
not new growth, the centre being occupied by pulpy material where
the abscess had originally been. Nothing else was discovered, and
there were no gallstones left, either in the gall-bladder or ducts. I
am able to show you the specimen and also a microscopic section, for
the preparation of both of which I have to thank Mr. Cammidge.
Chronic Pancreatitis. Chole cystotomy. On the 28th of January,
1901, Mr. E. R. H., aged twenty-six years, was sent to me from Mal-
vern. He was deeply jaundiced, and told me that he had had jaun-
dice since the age of seventeen, it having supervened upon a severe
attack of what appeared to be biliary colic, he having had several
seizures since the age of fourteen. For two or three years he had
had severe ague-like seizures, and during that time lost very seriously
in weight and strength, but during the last two years there had been
no shivers, and also he had been free from the severe paroxysms of
pain, though he had had slighter seizures, after all of which the jaun-
dice became more intense. The patient was then only weighing nine
stone, and all the bile was apparently passing in the urine and
none in the motions. There was also some swelling in the region
of the pancreas, slight enlargement of the liver, and a very decided
enlargement of the spleen.
Four days later the abdomen was opened by a vertical incision
through the right rectus. The gall-bladder was found contracted and
surrounded by numerous adhesions. After the separation of these
the ducts were carefully explored, but without discovering any gall-
stones. The head of the pancreas was found to be enlarged and very
hard. As the obstruction appeared to be entirely due to the pressure
exercised by the pancreas on the common duct, the gall-bladder was
drained. For a few days the jaundice was deeper. It then became
gradually less until it almost disappeared. In ten days the stools
ON PANCREATITIS. I7I
became bile-stained and have since retained their color, though there
has never been complete freedom from a tinge of jaundice to the
skin. He returned home on the i6th of April, having gained nearly
half a stone in weight. He looked and felt much better, and as a
email quantity of bile was still coming from the tube, it seemed desira-
ble to retain it until the last tinge of jaundice had disappeared. From
the first week of operation up to the present he has had no further
pain, and has been able to take ordinary food and digest it well.
172 DISCUSSION.
DISCUSSION.
Dr. George E. Brewer, of New York.
After listening to the able and instructive paper which our distin-
guished guest has just presented to us upon the subject of pancreatitis,
I must confess that it is with a very considerable feeling of diffidence,
and with no small measure of hesitation, that I rise to open the discus-
sion of a subject in which my personal experience has been so limited.
I feel, however, that I can at least offer the reader of the paper the
sincere thanks of the Association and assure him of our appreciation
of the courtesy he has shown us in coming this great distance to pre-
sent before the American Surgical Association the results of his accu-
mulated experience in this important surgical disease. That it is an
important surgical affection cannot for a moment be questioned when
we consider the constantly increasing mass of evidence which is being
furnished us from the autopsy-table of its serious nature, its frightful
mortality, and its obscure symptomatology. That the disease is of far
more frequent occurrence than is generally supposed is evidenced by
the fact that certain pioneers, like the writer of the paper, have had
such a large personal experience, and also by the fact that in certain
medical centres where the disease has been discussed extensively a
fairly large number of cases are annually reported. That it is not gen-
erally recognized by the profession at large is evidenced by the fact
that in other localities no reports of cases are presented.
In looking over some fifteen or twenty of the more recent annual
reports of a number of New York's largest hospitals, I find but one in
which the disease is spoken of as having been treated surgically. In
this single exception four cases are reported to have been operated
upon during one year. The reason of this failure to recognize this
disease is twofold, the first being that the attention of the profes-
sion has not been directed to it by the reports of cases and mono-
graphs on the subject, and the other is that sufficient data have not
been collected to enable us to present an accurate or complete cata-
logue of characteristic symptoms. As in the case of the pelvic inflam-
mations, of appendicitis, or inflammatory diseases of the biliary pas-
sages, and more recently in the perforative lesions of the stomach and
duodenum, many years elapsed after the earlier recorded cases before
the symptomatology of these conditions was generally recognized by
ON PANCREATITIS. 173
the medical profession. It seems to me, therefore, that it is important
for us as surgeons to be constantly on the watch for this disease, and
to accurately record and publish the clinical histories, results of opera-
tion, and autopsy findings of all cases of this fatal disorder which come
under our observation. This should be done, not only with a view to
calling the attention of the general medical public to the disease, but
also with a view to collecting data which by a later analysis may enable
us to get a more accurate idea of its pathology, clinical history, and
general behavior.
But it is not my intention, Mr. President, to dwell on the clinical
side of the case, for there are those here whose experience entitles
them to speak with far more authority. It has occurred to me that in
considering this question from a surgical point of view a review of the
anatomy of this region might be of interest, not only in explaining
some points in the clinical history of the disease and pathology, but
it also might furnish some suggestions regarding treatment. It will be
remembered that at a very early period in the development of the em-
bryo the pancreas is formed by two offshoots from the intestinal tube,
just below the gastric dilatation between the two layers of the poste-
rior mesentery. These two buds rapidly develop backward, giving off
numerous branches, which again divide and subdivide, forming an in-
numerable number of fine twigs, each one ending in a small epithelial-
lined sac. These are surrounded by minute plexuses of bloodvessels,
nerves, and lymphatics, and held together by areolar tissue, which, by
its distribution, divides the gland into a large number of segments or
lobules. The bud nearest the pylorus grows in this manner much
more rapidly than the one lower down, and soon forms the major part
of the gland. A few weeks later this fuses with the inferior gland, and
from that time on the two develop as a single structure. At a very
early period another outgrowth from the duodenal mucous membrane
occurs, which projects between the two layers of the anterior mesen-
tery. This afterward forms, by its development, the liver. The bile
duct, at first separate from the two pancreatic ducts, later fuses with the
lower duct, the two forming the ampulla of Vater, which opens into
the duodenum, as in the adult subject. A number of variations are
found in the adult human subject. The older anatomists taught that
the upper pancreatic duct gradually atrophied and only remained patent
in a few instances. Later investigation by improved methods shows
conclusively that the duct of Santorini is practically always present in
the human subject.
174 DISCUSSION.
I desire to present five or six photographs furnished me by Dr. Carl-
ton Flint, of the Anatomical Department of Columbia University,
showing the arrangement of the main and accessory ducts in some of
the lower animals and in the human subject.
Another point in the anatomy of this region to which I would like
to call attention is that the pancreas in the early stage of its develop-
ment is completely invested by peritoneum ; and that it only becomes
a retroperitoneal organ by the absorption and conversion into areolar
tissue and fat of the several layers of the posterior mesentery.
This fact I believe to be important clinically, for it will be seen that
the areolar tissue and fat surrounding the pancreas are directly continu-
ous with the perirenal and retrocolic areolar tissue on the left side —
a fact which explains the well-known tendency in suppurative disease
of the pancreas for the pus to burrow toward the left flank, and which
points out to us surgically the necessity of making counter openings for
drainage in this locality.
It is perhaps unnecessary to state to this Association that it is possible
to reach the pancreas by four different routes. These routes are : By
dividing the gastrohepatic omentum just above the lesser curvature of
the stomach ; by dividing the gastrocolic omentum just below the
greater curvature of the stomach ; by dividing the transverse meso-
colon, and by reflecting the parietal peritoneum through a lumbar
incision until the perirenal fat is reached, which is continuous with the
areolar tissue surrounding the pancreas.
Without entering on a discussion of the pathology of this condition,
which will be taken up by Dr. Opie, I desire to offer one suggestion, and
that is the probable causative relationship between an enlarged and
relaxed orifice of the ampulla of Vater due to the frequent passage of
biliary calculi and inflammatory diseases of both the bile duct and the
pancreatic duct, for it is a well-known and generally recognized fact that
in other situations of the body where a similar arrangement is found,
of ducts emptying into septic cavities, that whenever the sphincteric
action of the orifice is destroyed infection readily ascends to the
mucous membrane of the duct, giving rise to an inflammatory con-
dition which may vary in intensity from a mild catarrhal condition to
a severe, rapidly fatal interstitial inflammation of the entire gland. I
also desire to speak of the probably digestive action of the pancreatic
juice when allowed to percolate into the connective tissue surrounding
the gland as a cause of erosion of bloodvessels and extensive necrosis
in addition to the well-known power which it has of producing fat
ON PANCREATITIS. I75
necrosis. I desire, in conclusion, to refer to one or two cases of acute
pancreatitis, the autopsies of which furnish data which ought to be placed
on record.
E. G., male, aged fifty-three years, was admitted to Roosevelt Hos-
pital in August last. The patient had complained of a digestive dis-
order for many years. Seven years ago he experienced an attack of
severe abdominal pain which was accompanied by fever and was re-
garded as an acute peritonitis. From this he fully recovered. Five
days before his admission he complained of general abdominal pain,
which gradually increased and was accompanied by vomiting, fever,
and general malaise. Free catharsis produced no relief. His symp-
toms grew worse. A progressive distention of the abdomen ensued.
He had sweats, and became extremely weak and prostrated. On ad-
mission his temperature was 104.2° F. ; pulse, 100, but weak and
thready; respiration, 36 and shallow. The abdomen was greatly dis-
tended ; tenderness was everywhere present. No mass, no jaundice,
no fluid wave ; liver percussion normal. Heart and lungs negative.
Rectal examination negative. Urine negative. Bowels constipated.
He was seen by the writer about midnight, and, as his condition
seemed extremely critical, he was immediately prepared for operation.
As the clinical picture was one of a general peritonitis, the absence
of signs of gall-bladder disease, or the symptoms of a perforative lesion
of other portions of the alimentary tract, led us to a diagnosis by ex-
clusion of a perforated appendix.
Under chloroform anaesthesia the abdomen was opened. There was
no general peritonitis. The appendix region was thoroughly explored
and found to be normal. The gall-bladder region was next examined
and nothing of an inflammatory nature detected. As the intestines
were greatly distended, an obstruction was looked for, but not found.
All of this was done quickly, as the pulse was becoming rapidly weaker,
and the most vigorous stimulation was being employed, including a
hot saline infusion.
The region of the pancreas was next palpated through the walls of
the stomach and omental tissue, and pronounced negative by two ex-
aminers. There was, however, noticed a large number of small white
spots, generally distributed throughout the greater omentum, the largest
being about one-sixteenth of an inch in diameter. One of these was
removed for examination, after which the abdomen was qutckly closed
with generous gauze drainage.
The patient did not rally, and died the following day. A report
176 , DISCUSSION.
received from the hospital pathologist stated that the small white
nodule was of the nature of a fat necrosis, and the autopsy revealed
the pancreas to be the seat of a number of small circumscribed ab-
scesses. The case was, therefore, one of acute suppurative pancreatitis.
Dr. Eugene L. Opie, of Baltimore.
Surgeons and pathologists can be grateful to Mr. Robson for the
interest he has aroused in the relation of cholelithiasis to chronic pan-
creatitis. In his lecture published less than a year ago in the London
Lancet he proved conclusively that the induration so frequently ob-
served at operation' for gallstones in the common duct is due to
chronic interstitial pancreatitis. In two cases studied during the past
year I have found acute disease of the pancreas associated with the
presence of a small calculus in the common bile duct near its termi-
nation in the duodenum, and a review of the literature has demon-
strated the frequent coexistence of gallstones and acute pancreatitis.
There are, I believe, two mechanisms which explain this association
of gallstones with disease of the pancreas. The common bile duct, it
is well known, passes downward alongside of the head of the pancreas
to terminate in the duodenum. For a short but variable distance be-
fore reaching the duodenum it lies in contact with the pancreatic duct,
and, together with the two ducts, penetrates the wall of the intestine.
Before they open into the duodenum they unite to form a short com-
mon channel, the diverticulum of Vater. This diverticulum is very
variable in length and shape, but may be roughly described as a con-
ical cavity, at the apex of which is the common orifice of the two ducts,
while into its base open the orifices of the pancreatic and the bile duct.
The duodenal orifice of the diverticulum is narrower than any part of
the common bile duct, and here gallstones tend to lodge. These ana-
tomical features explain the two mechanisms by which gallstones may
produce lesions of the pancreas.
A small gallstone may lodge in the diverticulum at the common
orifice of the two ducts. The diverticulum, which varies greatly in
length, is often seven to eight millimetres in length, while the orifice
has a diameter of about two millimetres, although at times it is much
narrower. A small stone, perhaps from three to five millimetres in
diameter, might lodge in the diverticulum and occlude its duodenal
orifice, altKough it only partially filled the cavity of the diverticulum.
The orifices of the bile duct, the duct of Wirsung being unobstructed,
the two ducts would be converted by the occlusion of their common
ON PANCREATITIS. IJJ
orifice into a continuous closed channel, and bile might be forced by
the muscular contractions of the gallbladder into the pancreas. At the
autopsy performed upon a case occurring in the service of Dr. Halsted
at the Johns Hopkins Hospital I found the conditions mentioned. At
operation Dr. Halsted noted foci of fat necrosis disseminated through-
out the abdomen ; the pancreas was greatly swollen, blackish-red and
hemorrhagic in appearance. The patient died shortly after the oper-
ation, and at the autopsy, performed a few hours after death, the pan-
creas was found to be the seat of typical hemorrhagic pancreatitis,
characterized by extensive necrosis of tissue and accumulation of in-
flammatory exudate. A small gallstone, three millimetres in diameter,
was found lodged in the diverticulum of Vater, which was ten milli-
metres in length ; its orifice measured only one millimetre in diameter.
The stone had plugged the duodenal orifice of the diverticulum, but, only
partially filling its cavity, did not occlude either bile or pancreatic
duct. Bile had penetrated into the pancreatic duct, and its branches,
which mar the duodenum, were still intact, ind had stained them a
bright-green color. Cultures from the pancreas remained sterile.
Bile had made its way into the parenchyma, and its presence was asso-
ciated with acute hemorrhagic pancreatitis.
It has been shown that a variety of irritating substances injected
into the pancreatic duct of animals will produce acute hemorrhagic
pancreatitis resembling that in the human being. Flexner and others
have produced the lesion by the injection of artificial gastric juice,
acids, alkalies, dilute formalin, and suspensions of a variety of bacteria.
The autopsy referred to suggested the possibility that bile might also
produce the lesion, and experiments were, therefore, made on dogs.
About five cubic centimetres of bile obtained from the gall-bladder of
the same dog, or from that of a second dog, were injected into the
pancreatic duct. In four instances hemorrhagic pancreatitis, accom-
panied by focal fat necrosis, resulted, and in two of these cases the
lesion was fatal within twenty-four hours, wide-spread necrosis of the
abdominal fat being present. Smaller amounts of bile produced less
marked lesions. These facts, I believe, demonstrate that one at least
of the causes of hemorrhagic pancreatitis is the penetration of bile into
the pancreas, and explain the previously noted association of chole-
lithiasis with hemorrhagic and gangrenous pancreatitis, the latter being
doubtless a late stage of the hemorrhagic lesion.
There is a second mechanism by which gallstones can produce
changes in the pancreas. Should a gallstone of large size passing
Am Surg 13
1/8 DISCUSSION.
along the common duct become impacted in the diverticulum, it
would not only block the common orifice of the two ducts, but would
at the same time occlude the common bile duct and the duct of Wir-
sung, so that bile would be dammed back upon the liver and the pan-
creatic juice upon the pancreas. In this case bile could not enter the
pancreas. In order to occlude the pancreatic duct it would not be
necessary for the gallstone to enter the diverticulum, since, if it should
lodge in the bile duct just above the diverticulum, where the two
ducts are separated only by a thin septum, the pancreatic duct might
be compressed and obstructed. In a limited number of cases the
lesser duct of Santorini anastomoses with the larger pancreatic duct,
and hence provides an additional outlet for the secretion of the gland.
It is well known that occlusion of the pancreatic duct by calculi or by
carcinoma of the head of the pancreas is followed by a chronic inter-
stitial inflammation of the gland. When the pancreatic ducts of an
animal are ligated inflammation ensues. The chronic interstitial pan-
creatitis, which Mr. Robson has shown not infrequently accompany
cholelithiasis, is doubtless due to occlusion of the pancreatic duct by
gallstones impacted in the common duct near its termination or in the
diverticulum of Vater.
The association of pancreatic disease with the presence of gallstones
in the common duct and diverticulum of Vater appears to be of con-
siderable surgical importance. Acute or chronic pancreatitis is a pos-
sible complication in every case of cholelithiasis. The induration of
chronic inflammation observed at operation for gallstones has been
mistaken for malignant disease. The presence of abdominal fat ne-
crosis, or of hemorrhagic or gangrenous pancreatitis, should suggest the
possible presence of a gallstone in the diverticulum of Vater, and
should it remain so impacted the existing alteration of the pancreas
can only increase in severity.
Dr. J. W. Elliot, of Boston.
This contribution is one of the most important we have recently
had to the surgery of the gall-bladder, and since reading Dr. Rob-
son's paper in July, my own experience has confirmed his observa-
tions. I can recall one case of persistent jaundice where, having ex-
plored the gall-bladder and found no stone, but an abundance of black
bile and a thickened pancreas, I told the patient she was probably
suffering from malignant disease of the pancreas. She came to me
ON PANCREATITIS. 179
two years later, looking fat and feeling well. This was undoubtedly a
case of chronic pancreatitis obstructing the gall duct.
Another case of chronic pancreatitis which was associated with gall-
stones occurred in my practice last March, and is interesting as show-
ing why, with stones in the gall-bladder, we so frequently have the
symptom of jaundice. Theoretically, if the common duct were not
blocked there would be no jaundice ; but practically, surgeons know
that with stones only in the gall-bladder there is frequently jaundice.
The case was one of a man of middle age, who had lost much flesh
and had an increasing and persistent jaundice. The gall-bladder was
opened and the stones removed. None were found in the cystic duct
nor in the common duct. The pancreas was much enlarged and filled
with blebs. I thought it was either a case of cancer of the pancreas
or a chronic pancreatitis. No bile escaped at the time of operation,
but did so soon after, and the jaundice slowly disappeared. The gall-
bladder closed and the stools became normal in color. The man
came back two months later, having gained all the flesh he had lost,
and seemed to be perfectly well. In this case I simply drained the gall-
bladder, and as there was no stone in the common duct the jaundice
must have been caused by the enlarged pancreas, the drainage secur-
ing a perfect cure. In such cases I suppose the gallstones give rise to
a mild cholangitis, which extends into the pancreatic duct, giving rise
in turn to a chronic pancreatitis, which obstructs the common bile
duct.
Dr. George W. Fowler, of Brooklyn, N. Y.
I entirely agree in the opinion expressed that all cases upon this
subject should be recorded, and I wish to report three that have come
under my observation. The first one was several years ago, and very
little was known about the disease at that time. The patient gave a
history of some grave abdominal lesion, the main feature being in-
tense abdominal pain. Exploratory operation showed fat necrosis, and
a large number of orange-colored droplets came into view. There was
a large amount of rather thin dark material in the region of the pan-
creas, and the lesion undoubtedly had its origin in the head of that
organ. Drainage was instituted, but the patient died in a few hours,
the autopsy revealing the true lesion.
The second case was a woman who was brought to me with peculiar
symptoms of intense prostration. Her condition would not permit of
l80 DISCUSSION.
operation at the time, but the next morning she had rallied somewhat,
and preparations were made to operate. While these were going on
she again passed into a state of extreme collapse, and the operation
had to be abandoned. She finally rallied sufficiently to permit us to
open the abdomen. Hemorrhagic pancreatitis was found, and drainage
instituted, the patient m^aking a good recovery.
The third case was a man who came with a history of obscure diges-
tive disturbances and attacks of jaundice for several years. He was
supposed to be suffering from ordinary biliary colic ; the collapse present
was similar to the last case. After waiting some time for him to re-
cover from the collapse, the operation was finally instituted, and the
conditions found as already described. I do not know that this symp-
tom of repeated attacks of extreme collapse has been dwelt upon at
any length. It is mentioned in the literature, but is not sufficiently em-
phasized in the symptomatology of the disease. I wish to call atten-
tion to it, and to ask Dr. Robson if he has noticed it to be a promi-
nent feature.
Dr. N. B. Carson, of St. Louis.
The last speaker says that all cases should be reported, and I agree
with him. I have had one case in a young, fleshy lady, who gave a
history of numerous attacks of indigestion. I diagnosed chronic ap-
pendicitis, and on operating I found the appendix enlarged and thick-
ened. I supposed that she had made a good recovery ; but when I saw
her subsequently she stated that she had been suffering for a whole
year. She complained of having had numerous attacks resembling
gallstones, and was highly jaundiced. She had been jaundiced before,
but would recover, and then have another attack. These continued
for some time, and I diagnosed a probable pancreatitis and possibly
gallstones. I advised operation in order to explore and settle the
question. Upon operation I found the gall-bladder very much thick-
ened and slightly enlarged. On opening the gall-bladder a large
amount of clear mucus came out, followed by black gall. On ex-
ploring the abdomen I found the pancreas much indurated. I attached
the gall-bladder to the abdominal wall, and the patient made a slow
recovery. Just before leaving home I had a report from her attend-
ing physician, stating that she had had subsequent attacks resembling
indigestion, but that they were not accompanied with jaundice similar
to the previous attacks before the operation. The interesting fact was
how to explain the discharge of clear mucus which preceded the bile.
ON PANCREATITIS. l8l
When the bile assumed a natural color the patient commenced to
improve.
Dr. W. L. Estes, of South Bethlehem, Pa.
I wish to add another case to the list of chronic interstitial pan-
creatitis simulating carcinoma. My patient was a very robust man,
who had for six months pronounced jaundice, with symptoms which
indicated empyema of the gall-bladder. At the operation I found a
stone at the neck of the cystic duct, extending down far enough to
impede the flow of bile into the common duct. The head of the
pancreas was a nodular mass, which I diagnosed as carcinoma, and
gave a bad prognosis. The man recovered from the operation, and
made a very rapid recovery from the condition of fat necrosis. The
extreme weakness disappeared, and he is to-day a very robust police-
man.
I remember another case following injury, which is interesting in
light of Dr. Brewer's exposition of the anatomy and embryology of
the pancreatic region. The man had attempted to stop a runaway
horse, and was struck in the abdomen a little above the umbilical re-
gion. He did not pay much attention to it at the time, but the next
day had pain in the abdomen and some swelling. This distention
increased, and he was treated at his home for five weeks, during which
time he became progressively anaemic, and lost flesh to an amazing
degree, going down from 156 pounds to 95. He had a very large
tumor, occupying the whole upper quadrant of the abdomen, follow-
ing the curvature of the diaphragm ; a very tense, elastic tumor, which
reached from the diaphragm to a little below the umbilicus. The
whole upper part of the abdomen was the seat of the tumor, and this
was what puzzled me. The enlargement was slightly greater on the
left side, and I thought perhaps there was a retroperitoneal hemor-
rhage. I expected to find a large blood-clot and some serum, and
upon operation I found about two thousand cubic centimetres of bloody
serum. Although the stomach was stretched over this mass so tensely
that it seemed incapable of receiving anything within it, the man had
been able to take food in small quantities, but usually rejected it. The
stomach could not have held more than five cubic centimetres at any
time. I incised the cyst, drained it, washed it out, and sutured the
opening to the skin in the left lumbar region. I had the fluid ex-
amined, and found it to be pancreatic. Another and an interesting
physiological feature was that we collected from the cyst from fifteen
l82 DISCUSSION.
hundred to twenty-two hundred cubic centimetres of serum in a day
of twenty hours. The man made a slow but complete recovery.
His skin about the opening of the sinus, which led into the cyst, suf-
fered extensive excoriation from the discharging fluid, and as all fatty
protection was quickly digested, it was very difficult to prevent the
formation of a large superficial ulcer. Frequent bathings with boric
acid solution and frequent changes of dressing availed to prevent any
deep implication of the skin, and finally a closely fitting tube inserted
deep down into the cyst, with its external end inserted into a flask,
which was fastened to his side, served to conduct away the fluid and
to collect it. Many examinations and measurements of this fluid
were made, and there can be no doubt of its nature and its source.
Dr. Leonard Freeman, of Denver.
I wish to refer to a case in which marked jaundice had existed for
some time, with all the symptoms of a stone in the common duct,
although at the operation no stone was found. A very much thick-
ened, small and chronically inflamed gall-bladder, however, seemed
to give evidence that it had contained a calculus, which I imagined
had been recently expelled, perhaps during the operation. Although
the pancreas was extremely hard and its head unusually large, it did
not occur to me to suppose the symptoms had been due to the pan-
creatic disease. May not symptoms accredited to the pancreas some-
times be due to stones which afterward escape, before or during the
operation ?
Dr. Robson. As to the remarks made by one of the speakers, that
gallstones may be present without being discovered, I would state that
in some of the cases related I was unable to feel any stones, while in
others I could say positively they were not there ; but I do believe
that in nearly all the cases gallstones had been present at some time.
The cases related by the several speakers are very interesting, and
they show that this disease is very much more common than we have
thought. I have spoken with a large number of gentlemen who are
frequently operating in this region, and they have nearly all told me
of cases they had seen.
I was very much interested in what Dr. Fowler said about the col-
lapse which occurred in his cases, and I believe it does very frequently
occur. I have seen it in two cases, but not to the same extent as that
ON PANCREATITIS. 183
mentioned. I should very much like to know what treatment was
employed for the collapse, and what was the result.
(Dr. Fowler reported that strychnine was employed.)
I remember that in one case, where the collapse forbade operation
and persisted, the patient died without my having been able to get
him into condition for operation.
Dr. Opie raised several very interesting questions, and I had an op-
portunity this morning of seeing several of his beautiful specimens.
I was very much interested in them. One cannot help but feel that
the entrance of bile into the pancreatic ducts may offer an explana-
tion for some of these cases of hemorrhagic pancreatitis. I think it
may be rather the result of infection than of simple injection of bile
into the pancreatic ducts. It will certainly be interesting to hear
further of the results of Dr. Opie's investigations.
I enjoyed very much Dr. Brewer's description of the anatomy of the
pancreas, and it may be that the little accessory duct is a very impor-
tant factor. In one specimen of Dr. Opie's that I saw this morning
there is a small stone in the diverticulum, and in one of my cases I
removed a stone from the lower part of the common duct. This was
a case of chronic pancreatitis and not hemorrhagic. Where the gall-
stone is large we may actually get the bile forced into the little acces-
sory duct.
THE SURGICAL TREATMENT OF CHRONIC ULCER
OF THE STOMACH.
By a. W. mayo ROBSON, F.R.C.S.,
LEEDS, ENGLAND,
SENIOR SURGEON TO THE GENERAL INFIRMARY AT LEEDS ; EMERITUS PROFESSOR
OF SURGERY IN THE YORKSHIRE COLLEGE OF THE VICTORIA UNIVERSITY.
Mr. President: I must first thank you, sir, most sincerely
for the kind invitation which you personally and the Council
of the American Surgical Association have extended to me in
asking me to take part in your proceedings, an honor which I
very highly appreciate. The subject of the " Surgical Treat-
ment of Ulcer of the Stomach" is one that has for some time
and is now attracting the attention of surgeons all over the
world, so that I hope I shall need to make no apology for ven-
tilating my views before this important Surgical Association.
The treatment of gastric ulcer is at first essentially medical,
and when properly carried out and for a sufficient length of
time it is usually completely successful. Leube says that one-
half or three- fourths of all cases will be cured by four or five
weeks of treatment, but if not cured in that time they will not
be cured by medical treatment alone, a view in which I thor-
oughly concur. Unfortunately, however, in many cases, treat-
ment is stopped as soon as relief to pain is obtained and long
before the ulcer is healed. In some cases this may be due to
the uncertainty of the diagnosis or from the impatience of the
patient; perhaps, in others, to ignorance as to how long it takes
to secure the healing of a gastric ulcer. The earlier in the course
of the disease that radical treatment, in the shape of dieting and
rest, is adopted the less prolonged will the treatment need to be
and the more likely is it to be effectual ; but probably the very
CHRONIC ULCER OF THE STOMACH. 185
earliest time that a patient should be allowed to be out of bed is
from a fortnight to a month after all pain and tenderness have
disappeared.
Failing this thorough treatment relapses will be certain to
occur, and in the long run complications will supervene or the
ulcer will become chronic, when, though medical treatment may-
relieve in some cases, cure can only be looked for in the greater
number by surgical methods.
In considering the treatment of ulcer of the stomach, it is
useful to hold in view the course of an ulcer of the leg, which
directly the healing stage has arrived becomes free from pain ;
but this neither indicates that healing is completed nor that
care may cease, and should treatment be abandoned and the
ulcer become chronic, though it may even then be painless, it
is at any time liable to become inflamed. or to extend; more-
over, the surrounding tissues become infiltrated with lymph
which tends to organize, and this in a hollow viscus soon ends
in stricture, as in the leg it tends to drag on the surrounding
skin and produce constriction of the limb.
The surgical treatme?tt of intractable or relapsing gastric ulcer
is in the greater number of cases the only satisfactory method
of dealing with these refractory cases, and operation should
be resorted to at a much earlier period than has hitherto been
the custom, and always before the patient is so far reduced by
pain and starvation, or the supervention of serious complica-
tions, that weakness and anaemia render any operative proce-
dure hazardous.
Ulcer of the stomach is a much more serious matter than is
generally recognized, for, according to various authors, it has a
mortality when treated by general and medical means only of
from 20 to 50 per cent.
Dr. Einhorn, in his well-known work on Diseases of the Stom-
ach (p. 223), says : "At first glance it would appear that the
prognosis of gastric ulcer is quite good, especially nowadays,
when the diagnosis of the affection is usually made at an early
date. However, if we take into consideration the tabulated
statistics given by Debove and Remond (page 276), in reference
I 86 ROB SON,
to the outcome of all cases of ulcer, we become more careful in
our favorable predictions."
This table gives in a hundred cases of ulcer :
Perfect cure . 50
Perforation and peritonitis . . . . . . . • 13
Foudroyant hasmatemesis ......... 5
Pulmonary tuberculosis . . . . . . . . .20
Inanition ............ 5
Different complications ......... 7
The excuses of a few years ago, that there is a great respon-
sibility in recommending surgical treatment, either from the un-
certainties of diagnosis or from the risk of operation, can no
longer avail, since the diagnosis of gastric ulcer, thanks to the
researches of Ewald, Hemmeter, Hinborn and others, has been
brought to a greater state of perfection than exists in many
other obscure diseases, where radical treatment has to be
adopted on much more slender foundations ; and fortunately,
now that the mortality in operations for simple diseases of the
stomach, excluding perforation and hemorrhage, has been re-
duced in the hands of experienced surgeons to about 5 per cent.,
the great risks of surgical treatment cannot be advanced even
by its most ardent opponents.
We have to consider not only the treatment of gastric ulcer
itself, but also that of all its complications, which are no less
numerous than serious. They are as follows :
1. Local peritonitis or perigastritis ending in adhesions.
2. Local peritonitis ending in suppuration and a localized
abscess.
3. Subphrenic abscess.
4. Abscess of liver, pancreas, or spleen.
5. Fistula between the stomach or pylorus and adjoining
organs, or with the surface of the body.
6. Acute perforation of the stomach wall.
7. General peritonitis.
8. Haematemesis and mela^na.
9. Dilatation of the stomach.
10. Tumor of stomach or pylorus.
CHRONIC ULCER OF THE STOMACH. 187
11. Cicatricial stenosis of pylorus.
12. Hour-glass stomach.
13. Spasm of pylorus, producing intermittent narrowing
(Reichman's disease).
14. Atonic motor deficiency.
15. Severe gastralgia.
16. Persistent vomiting.
17. Tetany.
18. Acute or chronic pancreatitis.
19. Profound anji^mia, resembling the pernicious form.
20. Pressure on or stricture of the bile ducts, with jaundice.
21. Catarrh of gall-bladder from adhesions producing attacks
like those of cholelithiasis.
22. Great loss of flesh and strength ending in phthisis.
23. Cancer secondary to ulcer. " Ulcus carcinomatosum."
We are not prepared to subscribe fully to the views of Tri-
comi/ who draws a parallel between the treatment of hernia
and that of ordinary gastric ulcer, and proposes that, as hernia
is treated radically with success, so gastric ulcer should be
treated radically by the performance of gastro -enterostomy.
Heydenreich- argues : " The death rate from all cases of gastric
ulcer is from 25 to 30 per cent., but from gastro-enterostomy
only 16.2 per cent. ; therefore, the operation has less danger
than the disease."
The question of medical vs. surgical treatment in this class of
cases is, however, one that can be much simplified by a careful
study of statistics.
At the time I delivered the Hunterian Lectures, in March,
1900, I had been able to collect from various sources 188 opera-
tions on the stomach for gastric ulcer (excluding those for per-
foration and hemorrhage), of which 157 recovered and 31 died,
thus giving a mortality of 16.4 per. cent. These included 34
personal cases.
Now, although the deaths from gastric ulcer medically
treated averaged 25 per cent., taking a low estimate, and those
1 Riforma Medica, 1889. - Sem. Med., February 2, 1898.
l88 ROBSON,
from even the worst and most inveterate cases of ulcer, when
treated surgically, only i6 per cent, at the time of those lectures,
yet the difference did not then appear so great as to make it
desirable or prudent very strongly to advocate surgical treat-
ment until the disease became chronic or until serious compli-
cations had ensued.
To-day, however, the facts are very materially altered by the
all-round improvement in operations on the stomach, and the
contrast of 25 per cent, of deaths in cases treated medically, and
5 per cent, as shown in our latest statistics in those treated
surgically, in the worst and most complicated cases, is so strik-
ing that we feel it incumbent to urge most strongly that,
although cases of gastric ulcer should first be submitted to
medical treatment, yet if such treatment fails to cure in a rea-
sonable time, or if relapses occur on the resumption of solid
food, then surgical should give place to medical treatment ; for
it is unfair to the surgeon to hand over to him almost moribund
cases, and it is unjust to the patients to persist in dosing them
with medicine, or otherwise treating palliatively, cases that can
only be benefited or cured by surgical means.
Operative Treatment. Before the abdomen is opened it is
quite impossible to say what operation or operations will be re-
quired, and the surgeon must be prepared to adapt himself to
circumstances on discovering the position of the ulcer and the
conditions associated with it, especially as to the presence or
absence of adhesions and other complications.
Any one of the following operations or a combination of one
or more may be called for in each individual case: Exploratory
gastrotomy ; gastro-enterostomy to secure physiological rest to
the stomach and relieve the hyperchlorhydria, or in other cases
to short-circuit a stenosis; excision of the \x\ccr \ pylorectomy ;
pyoroplasty ; gastroplasty ; gastrogastrostomy ; gastrolysis ; pylo-
rodiosis ; gastroplication.
The Preparation of the Patient. It has been the custom with
many surgeons to put stomach patients through a long course
of preliminary treatment, such as frequent lavage of the stom-
ach and abstention from food before operation ; this, as a rule.
CHRONIC ULCER OF THE STOMACH. 189
is quite unnecessary, and certainly inadvisable in the greater
number of cases ; first, because the treatment is depressing and
debilitating in the case of patients already exhausted by long
illness ; secondly, as proved by Dr. Harvey Cushing's bacterio-
logical investigations, the stomach contents speedily become
aseptic if the mouth be cleansed and aseptic foods admin-
istered ; and thirdly, as proved by ample clinical experience,
elaborate preliminary treatment is unnecessary to success.
If the stomach is greatly dilated and the contents are foul,
then lavage with simple boiled water night and morning is
adopted for two days before operation. The careful cleansing
of the mouth and teeth and the administration of foods steril-
ized by boiling is advisable. The last meal is given the night
before, about twelve hours, the stomach is washed out about
two hours, and a nutrient enema given about an hour before
operation.
In other cases no lavage is adopted, but the same care is ex-
ercised in cleansing the mouth, giving sterilized food and admin-
istering a nutrient enema, consisting of one ounce of brandy,
one ounce of liquid peptonoids, and ten ounces of normal saline
solution. Every patient is enveloped in a suit of cotton-wool,
made by the nurse out of gamgee tissue, and each has an in-
jection of ten minims of liq. strychninae, B. P., administered
subcutaneously before the operation is begun.
The preparation of the skin and other aseptic details of the
operation differ in no respect from those observed in operations
generally.
Exploratory gastrotomy ^ or opening the stomach by a free in-
cision in its anterior wall, is an operation occasionally called for
in the surgical treatment of ulcer.
[a) In order to verify the diagnosis of ulcer when there is so
much thickening of the stomach walls as to suggest the pres-
ence of cancer.
{b) When, although the symptoms have pointed to ulcer as
the cause of the gastric trouble, the stomach, on exposure, be-
trays no evidence of puckering or other characteristic signs,
and when, in order to verify the diagnosis and ascertain what is
190 ROBSON,
best to be done, it is felt desirable to examine the interior of
the organ.
(c) In certain cases of gastrorrhagia it is desirable to perform
exploratory gastrotomy in order to find and ligature the bleed-
ing vessels or to otherwise arrest the hemorrhage,
(d) It necessarily forms part of any operation for the excision
of ulcer of the stomach.
It is not necessary for me here to enter into any detailed de-
scription of the operation, which must be familiar to all my
hearers, and which requires to be varied according to the object
in view.
The following are examples of exploratory gastrotomy for
ulcer:
Man, aged thirty-six years; symptoms of chronic ulcer ex-
tending over several years. On exposure of the stomach no evi-
dence on surface to indicate accuracy of diagnosis. Exploratory
gastrotomy : discovery of large ulcer one and a half by three
inches on the posterior wall of the stomach. Posterior gastro-
enterostomy ; recovery.
Acute gastrorrhagia; no evidence on exposing stomach ; ex-
ploratory gastrotomy ; numerous bleeding ulcers seen, two of
which were bleeding freely, and were ligatured en masse ; gastro-
enterostomy ; recovery.
Excision of ulcer is, as a rule, unnecessary, but not always to
be avoided, as in some cases of bleeding ulcer, and in others
where the thickening and induration render it difficult to decide
on the absence of malignant disease. This was the case in a
man, aged fifty-four years, on whom I operated in 1891, when,
finding the pylorus the seat of diffuse induration, excision of the
whole indurated area was performed successfully. A careful
examination of the removed mass showed that the growth was
inflammatory around a chronic ulcer.
In another middle-aged man, where the diffuse induration was
suggestive of cancer, the pylorus was opened and a deep ulcer
on the posterior wall successfully excised, the edges of the orig-
inal incision as well as the margins of the posterior wound being
brought together in a direction transverse to the axis of the
CHRONIC ULCER OF THE STOMACH. I9I
pylorus over a bone bobbin, as in the modified operation of
gastro-enterostomy.
Rydygier prefers excision of the ulcer to gastro-enterostomy,
because he believes that carcinoma not infrequently develops in
the scar of an old ulcer.
After excision of an ulcer the bleeding from large vessels
must be controlled by ligature, but the oozing from the smaller
vessels will be stopped readily by the continuous suture em-
ployed to bring together the edges of the wound. If the ex-
cision involves the serous coat, a Lembert continuous stitch,
with a silk or celluloid suture, will be necessary. Should the
excision have been near the pylorus the line of suture must be
placed transversely to the axis of the canal, so as to avoid
stricture.
The following cases are examples of gastric ulcers treated by
excision :
Case I. Ulcer of pylorus ; stenosis; dilatation of stomach ; excision
of ulcer and pyloroplasty. — John W. R., aged thirty-six years, ad-
mitted to the Leeds Infirmary with the history of stomach trouble for
thirteen years. Pain after food and vomiting were the initial symp-
toms. Severe heematemesis occurred six years after the commence-
ment of symptoms. Great loss of flesh and weakness were followed
by inability to work, although he had stomach lavage and other appro-
priate treatmentc On admission the patient was very thin and pro-
foundly weak. He weighed eight stone. A swelling could be felt
below the right costal margin. The stomach reached three inches
below the umbilicus, and there was visible peristalsis. Free HCl pre-
sent.
Operation on November 15, 1900. The pylorus was found very
much thickened, forming a nodular swelling adherent to the gall-
bladder and liver and to the abdominal wall by omental adhesions.
After separating the adhesions a small opening was discovered in front
of the pylorus, evidently the site of a perforation which his medical
man, who was present, said he remembered occurring some months
previously, and which was then treated successfully by rest and rectal
feeding.
The pylorus was freely laid open and found to be the site of a round
perforating ulcer in front and another on the posterior wall. The latter
192 ROBSON,
had perforated into the substance of the pancreas. Both were excised,
thus practically constituting a pylorectomy. The edges of the poste-
rior wound were brought together transversely to the axis of the stomach.
The anterior wound was prolonged into the duodenum and stomach,
and its edges were brought together transversely to the axis of the
stomach over a bone bobbin, thus leaving a capacious channel between
the stomach and duodenum surrounded by healthy mucous membrane.
Recovery was uninterrupted, and he was discharged on December
1 2th, weighing 8 stone 5 pounds.
On January 9, 1901, he returned to report himself well, and then
weighed 9 stone 11 pounds.
Case II. Pyloric ulcer treated by excision of ulcer and pyloroplasty. —
Mrs. M. K., aged forty-four years. Well till two years ago, when she
had colic and lost flesh. Under treatment, recovered and gained
some of lost weight.
September 15, 1897. Recurrence of attack similar to that of a year
before, but with pain at the right side, over the pylorus. Loss of weight
and strength. The patient had for some time been an invalid, and
had been continuously under medical treatment for months. Her
weight was 6 stone 11 pounds. There was visible peristalsis toward
the pylorus, which was fixed to the gall-bladder ; no pain or tender-
ness. Liver two inches below costal margin, but no nodules, and no
jaundice present.
Operation on July 23, 1898. An ulcer at the pylorus was found
adherent to the liver, which formed its floor, and there was stenosis of
pylorus. Pyloroplasty performed after excision of the ulcer, the open-
ing being sutured transversely over a bone bobbin.
December T^, 1898. Had gained i stone 8 pounds in weight. No
trouble in digesting anything.
December 23, 1899. Reported as "very well" and of normal
weight.
The operatioji of pylorectomy for ulceration of the pylorus may
be conveniently mentioned under the heading of excision of
ulcer.
Dr. Rodman^ has collected from literature and personal cor-
respondence detailed reports of forty pylorectomies, partial
gastrectomies, and excisions for ulcer, with six deaths. This
1 Philadelphia Medical Journal, June 9, 1900.
CHRONIC ULCER OF THE STOMACH, I93
includes cases since 1881, but the later operations, under im-
proved technique, contrast favorably with the earlier ones.
I have myself performed the operation of excision of gastric
ulcer six times, all the patients recovering.
Nevertheless, the mortality after excision will probably always
be higher than the more simple operation of gastro-enterostomy.
The more severe and radical operation should, therefore, be re-
served for cases that are not suitable for the less severe opera-
tion, or in which the suspicion of cancerous degeneration is
entertained, and cannot be disproved on naked-eye inspection.
The following case is an example :
Tumor of pyloi'us and chronic hcematemesis due to ulcer ; pylorectoviy. —
Ini 89 1 1 was asked by a medical friend to see a man, aged fifty-four years,
who for six months had suffered from pain coming on an hour after
food, and more recently from vomiting blood,. of coffee-ground charac-
ter, in considerable quantities, so that he was not only reduced in flesh
and strength, but had also been rendered profoundly anaemic by the
loss of blood.
A tumor of the pylorus could be easily felt, and the stomach was
markedly dilated.
As he was rapidly losing ground, an operation was performed, and
the pylorus was found thickened and nodular, with adhesions to the
liver and omentum.
After separating the adhesions the pylorus was excised, and the open
end of the duodenum was fixed to the opening in the stomach by
means of two lines of sutures without the use of a bobbin, the rest of
the stomach aperture being closed by a double layer of sutures. The
tumor proved to be inflammatory around an open ulcer, which had
been the source of the hemorrhage. The bleeding was not repeated,
and the patient rapidly gained flesh, and returned home within the
month.
The subsequent history of this case is interesting on account
of cicatricial contraction of the new pyloric aperture, which led
to the invention and employment of a decalcified bone bobbin
to act as a temporary splint, over which to apply the sutures,
and thus to secure a large aperture which has little tendency to
contract.
Am Surg 13
194 ROBSON,
Gastro-enterostomy , in the absence of special complications, is
the operation to be relied on in the treatment of ulcer of the
stomach. It acts by securing physiological rest by means of
drainage, thus allowing the ulcer to heal without being subjected
to the irritation of acid secretion, accumulation of food or fre-
quent stomach movement. It also, while remedying the hyper-
chlorhydria, relieves pyloric spasm, and while preventing stagna-
tion of fermenting fluids materially diminishes gastric dilatation.
The posterior operation is the one I personally prefer, the junc-
tion of the posterior wall of the stomach with the first part of
the jejunum being effected by two continuous sutures with or
without a decalcified bone bobbin.
The use of a bone bobbin not only secures an ample and im-
mediately patent opening between the two viscera for the pass-
age of the stomach contents, but protects the line of union from
the irritation of the stomach contents.
The whole operation can be easily completed in half an hour,
and it may even be done in half the time. Along with my col-
league, Mr. Moynihan, I have given my full experience of the
operation and of stomach surgery in general, in book form, now
in the hands of the publishers, Messrs. Balliere, Tindall & Cox.
Our experience with the posterior operation has been very
favorable, not only in the rate of the recovery of the patients,
but in the smoothness of the recovery, many of the patients
recovering without even once vomiting, and only on two occa-
sions have we seen regurgitant vomiting of bile, which, in the
anterior operation, is much more frequently seen, and at times
becomes serious, or even leads to a fatal issue.
We have performed the posterior operation on forty patients,
with two deaths, or an average mortality of 5 per cent, but
as the deaths were from more or less accidental causes, which
should be avoided in the future, and occurred, respectively, on
the tenth and eleventh days after operation, during the whole of
which time the patients had been able to take and assimilate food,
the gastro-enterostomy, per se, cannot be blamed for the result,
and which might, under similar circumstances, have occurred
after any operation.
CHRONIC ULCER OF THE STOMACH. I95
Dr. Fantino ^ examined Professor Carle's cases of gastro-
enterostomy as regards the following points :
1. Changes in the peristalsis of the stomach.
2. The ability or non-ability of the new sphincters to close
the outlet.
3. The capacity of the stomach.
4. The secretion of hydrochloric acid.
In the cases examined the operation immediately improved
the peristaltic power of the stomach, though it did not render
it normal. The stomach could generally empty itself, but did
so gradually. Systematic examinations of the stomach con-
tents were made after test-meals, etc., and showed that after an
irregular period the stomach regained completely its power of
emptying itself; in fact, as a rule, after gastro-enterostomy the
stomach would be found practically empty in three to five hours
after a meal. Generally, it was found that the stomach decreased
in size soon after gastro-enterostomy, so that the formerly dis-
tended organ became normal in size. Examinations of the
stomach by means of distention with carbonic acid and by other
methods showed that a sphincter was developed at the new
opening, and that its power increased with time.
The secretion of hydrochloric acid after operation was
studied :
In cases where there was formerly hyperacidity this condi-
tion was lost, and though the degree of acidity in any indi-
vidual case varied from time to time, yet these variations did
not depart from physiological limits. In the same examinations"
it was found that regurgitation of bile into the stomach took
place, but it was of no importance so long as the outlet from
the organ was sufficient.
Cases of hypo- and anacidity showed no change in their
gastric juice after operation, showing clearly that this condition
is not dependent on obstruction, but on previous changes in the
mucous membranes, these changes being probably in the
nature of an atrophy of the peptogastric glands.
1 Archiv fiir klinische Chirurgie, xlix., i and 2.
196 ROBSON,
The following cases are given as examples of the treatment
of gastric ulcer by gastro-enterostomy.
Case I. — Mrs. W., aged thirty-two years. Pyloric ulcer, treated by
pyloroplasty, with subsequent contraction, Gastro-enterostomy —
pyloroplasty, during active ulceration of pylorus, in December, 1895,
Great relief for a time, but later recurrence of dilatation, vomiting,
pain, and other symptoms. Very considerable loss of flesh. Patient
thin and anaemic ; pulse feeble and rapid, marked dilatation, the
stomach reaching well below the umbilicus.
October 10, 1898, Operation. Gastro-enterostomy (bone bobbin
employed). In October, 1899, patient well and active. February,
1900, had gained i stone 10 pounds.
Case II, — Mr. M. A., aged twenty-eight years. Pyloric ulcer;
tumor of pylorus ; gastro-enterostomy. Two years ago was 1 2 stone
12 pounds, now 9 stone 6 pounds. Pain two hours after food. For
last two months vomiting on an average five times a week, twice
coffee-ground vomit. Enormous dilatation of stomach. Pyloric
tumor movable, visible peristalsis.
August 4, 1899. Operation. Large mass at pylorus, evidently
thickening, due to ulceration ; glands large, but not matted. Gastro-
enterostomy (bone bobbin used).
2']th. Good recovery. Weight, 9 stone 7 pounds,
September 20th. Weight, 10 stone 13 pounds. Can eat anything.
Well, 1 90 1.
Case III. — Mr. D. B., aged thirty-one years. Extensive ulceration
of stomach, with large tumor. Gastro-enterostomy (anterior).
Dyspepsia seventeen years. More severe last twenty months. Six-
teen months ago vomiting recurred, and from outset large quantities
ejected, but never containing blood. Recurrence occasionally of
similar attacks, always relieved by treatment.
December, 1897, stomach reached pubes, and visible peristalsis seen.
Relief followed dieting and lavage till March, 1898, since which time
pain almost constant. Pain not materially worse after food, nor
relieved by vomiting. Loss of weight from 10 stone to 8 stone 6^
pounds. Great feebleness.
May 6, 1898. Operation. Large irregular tumor at pylorus and
along lesser curvature, but glands, though large, discrete. Gastro-
enterostomy (bone bobbin employed). Eight stone in weight when
he left the home, July 7, 1898,
CHRONIC ULCER OF THE STOMACH. I97
August \ith. Weighs 9 stone 3 pounds. Letter dated February
12, 1900, to say: " My health continues perfect. I have not lost a
day's work through illness since I recovered."
Case IV. — Miss H,, aged thirty-two years, sent to me with a history
of stomach symptoms extending over several years. She had had
haematemesis in 1S92 and 1896, since which time she had suffered
from flatulency and pain after food. For two years epigastric pain
constant, but increased by food. A year ago vomited daily, then
relief for a time, but for some months only milk could be retained.
Epigastric tenderness was well marked, and on distending the stomach
with CO2 it reached half an inch below the umbilicus and far over
to the right of the middle line.
October 'i^, 1900. Posterior gastro-enterostomy performed, a bone
bobbin being employed.
Recovery uninterrupted. Returned home within the month, taking
solid food without any discomfort, and gaining flesh.
On November 8th Dr. A. writes: "I have' seen Miss H. since her
return, and there is every reason to be pleased with her condition.
She has lost all her pain, and is taking food well. Allow me to thank
you for her restoration to comparative health."
Report of weight February i, 1901, 8 stone 6 pounds; at time of
operation, 6 stone 12 pounds.
Case V. — Mr. H., aged fifty-two years, began to suffer in 1897 from
symptoms of ulcer of stomach, which were relieved by restricted diet
and general treatment, but in July, 1899, the symptoms returned, with
great loss of flesh and strength. Well-marked dilatation of the stomach
was discovered and operative treatment advised.
Lavage and other treatment was carried out in London and in Scot-
land, but without material improvement.
When first seen by me there was visible peristalsis, with well-marked
stomach splash and a tender spot under the right costal margin. Al-
though tall, the patient only weighed 8 stone 10 pounds, and he was
extremely weak and pallid.
October 12, 1900. Operation. Hour-glass stomach found, but the
stricture was not extreme. Puckering on anterior wall of the stdmach,
with well-marked thickening. Free HCl discovered in the stomach
contents.
Posterior gastro-enterostomy performed. Good recovery.
March ^, 1901. Patient wrote from Bournemouth saying : "I am
pleased to be able to tell you that I have had no return of my former
198 ROB SON,
complaint, and that I eat, drink, and sleep well. Have got back to
my former weight.
Case VI. — History. J. S., aged forty-five years, residing at Batley ;
gave the history of two years' pain about an hour after food, with great
loss of flesh. For nine months he had vomited every day or every
second day a large quantity of yeasty material, but no blood, though
he was very anaemic.
There were well-marked signs of dilatation, with tenderness over
the pylorus.
lune 12, 1900. Operation. On opening the abdomen the pylorus
was much thickened and adherent, forming a tumor, and through the
centre of the mass a No. 10 catheter could only be passed, over a
roughened, ulcerated surface. A posterior gastro-enterostomy was
performed .
After-history. An uninterrupted recovery followed. Food was
begun the second day, and solids could be taken in the second week
without pain. He rapidly gained flesh and strength, and is now well.
The following case illustrates the value of gastro-enterostomy
in acute haematemesis.
Chronic ulcers ; hczmatetnesis ; gastro-enterostomy. Mr. F., a farmer,
residing in Essex, was sent to me by Dr. A. J. T. White, on March 25,
1901, and he kindly furnished the following history :
" I first saw Mr. F. five years ago ; he had then occasional pain in
the epigastrium, with much flatulence, and at times vomiting. This
kept on at intervals more or less for three years. Eighteen months ago
Dr. G. saw him with me. At that time, instead of his former weight
of 16 stone, he only turned the scale at 12 stone. He then improved
gradually for about three months, and gained about a stone in weight.
Six months later, or about a year ago, he, while out driving, had some
abdominal pain, and vomited considerable quantities of blood. He
continued being sick and suff"ering for some time, with slight haema-
temesis and meljena, but again improved. About three or four months
ago he got worse, and has been vomiting and suffering considerable
pain on and off ever since. I have very little doubt but that this
original trouble was gastric ulcer, but my fear now is lest malignant
ulceration should have supervened, and some time ago I asked him to
see you. He could not go then, as he had various business matters to
CHRONIC ULCER OF THE STOMACH. I99
set right, but now is willing. He is a man of iron will and constitu-
tion, though terribly pulled down."
On Mr. F.'s arrival in Leeds he went direct to a surgical home,
his weight then being 10 stone. He was suffering severe pain, but
was able to take a little milk, which was, in fact, the only form of food
he had been able to digest for a long time. Within a few hours he was
seized with violent hsematemesis and vomited five pints of clots and
dark fluid mixed with mucus. Rectal feeding was at once adopted,
and an ice bag applied to the epigastrium. The next day much coffee-
ground material was vomited, and on the third day the bleeding ceased.
An operation, which was clearly demanded, was arranged for March
22d, but on the night of the 21st he again vomited two pewters full of
pure, dark blood, which clotted soon after being vomited. The stomach
was quite empty of food, as after the night of his admission feeding
had been entirely rectal. He was now extremely weak ; but as the
vomiting and bleeding were continuing. Dr. White agreed with me
that it would be better not to postpone operation, for he was rapidly
losing ground, and clearly could not stand a greater loss. An hour
before operation he vomited blood freely again.
On the morning of March 22d, on opening the abdomen, the lesser
curvature of the stomach was found to be much indurated, forming a
tumor. There was also much puckering of the surface of the stomach,
and the glands in the greater and lesser omentum were enlarged, but
discrete. A posterior gastro-enterostomy was performed, a bone bob-
bin being used. In order to guard against shock he was enveloped in
cotton-wool; had ten minims of liq. strychnise, B. P., given sub-
cutaneously before operation, and had a pint of saline fluid, with an
ounce of brandy, given into the bowel. Immediately after operation,
which was finished within the half hour, nearly a pint of saline fluid
was injected into the subcutaneous tissues of the axilla, and another
pint, together with an ounce of brandy, administered per rectum.
During the day three injections, of five minims of liq. strychnise,
were given, and the rectal enemata were repeated.
Very little shock was felt, and the after-progress was uninterrupted.
The bowels were moved on the third day, and the wound was dressed
and found healed on the tenth. No more blood was parted with, and
stomach-feeding was begun four days after operation. By the end of
the week he was taking as much as five pints of fluid nourishment in
the twenty-four hours. He said he had never had any pain since the
operation, and was feeling better than he had done for a long time.
200 R O B S O N ,
He had lost all the acid eructations, the constant burning at the epi-
gastrium, and the flatulency. He returned home within the month
very well, and, as showing the state of his digestion, he had gained
4 pounds in the week before he left the surgical home.
Pyloroplasty , as a curative measure in this class of cases, has
certain very definite limitations, but where it is feasible it is a
method of great utility, which can be performed rapidly and
with very little exposure of viscera. Pyloroplasty, if the pylorus
be stenosed, free from extensive adhesions, easily drawn for-
ward, and not actively ulcerating, is a simple and short opera-
tion, and in quite a number of cases, of both gastric and pyloric
ulcer, I have found it to answer well. It must not be relied on,
however, where active ulceration of the pylorus itself is found,
unless at the same time the ulcer be completely excised ; other-
wise cicatricial contraction will follow. It acts in the same way
as does gastro-enterostomy — by affording a free exit to the
stomach contents, and thus securing physiological rest to the
stomach.
The histories to be related exemplify the complete success
which attended the operation in appropriate cases, and also the
disappointment which followed its employment in one of the
earlier examples, which, owing to inexperience, was not properly
selected.
Professor Carle and Fantino' compare the operation of gastro-
enterostomy and pyloroplasty. Out of 14 cases in which the
latter operation was performed, only i died.
The results of pyloroplasty, as regards function, have been
little noticed in literature. To the author's 14 cases, 3 may be
added where the operation was by tearing, but the results were
the same. In all the 17 cases the results were excellent; in 13
of them perfect and permanent, as it is now from three to seven
years since operation. In these the condition of the secretions
and of the peristaltic power of the stomach was the same as
after gastro-enterostomy for non-malignant stenosis. Diminu-
tion in size of the stomach was not so marked as would be ex-
' Loc. cit.
CHRONIC ULCER OF THE STOMACH. 2C I
pected in the presence of such remarkable recovery of the gen-
eral health and of the stomach's power to empty itself. In all
cases, with one exception, the gastric capacity was more or less
diminished; but in no case did it become normal in size.
A few cases must be excepted where operation was performed
for hyperacidity with gastric atony. In these, four or five months
after operation, there was delayed evacuation of the stomach and
a feeling of weight. Although the general improvement was
considerable, yet the authors were persuaded that a posterior
gastro-enterostomy would have given better results. In one of
the cases a subsequent gastro-enterostomy gave a perfect re-
covery.
In cases where there was hyperacidity before the operation
there was a rapid return to the normal, but not to below normal,
as was found after gastro-enterostomy. The authors believe
that the rapid and great diminution in hydrochloric acid after
the latter operation is due to the very rapid evacuation of the
stomach after a meal, and do not deny the possible influence of
a regurgitation of bile into the stomach. Both these conditions
are absent after pyloroplasty, hence the difference in secretion.
In cases of hypo- and anacidity, operation produced no change
in this particular, and yet health was restored. The results of
pyloroplasty may be summarized :
1. Regurgitation of bile into the stomach is prevented.
2. Secretion of hydrochloric acid, when it has been exces-
sive, becomes normal.
3. If the secretion of hydrochloric acid has been diminished
or absent before operation, it remains in statu quo after opera-
tion.
4. If there has been primary gastric atony, peristalsis is but
little improved.
5. This function improves rapidly or reaches perfection if the
muscular contractility has been normal or increased, and when
the obstruction was due to fibrous stenosis or pyloric spasm.
6. In all such cases evacuation of the stomach is accomplished
in its physiological period. Only in rare cases, and these only
in the first months after operation, may it be delayed.
202 R O B S O N ,
7. The capacity of the stomach always decreases, but rarely
becomes as small as normal.
8. The pylorus recovers tone.
Points of difference between the results of pyloroplasty and
gastro-enterostomy are :
1. The absence of regurgitation of bile, and hence the absence
of any possible biliary influence on the gastric secretions.
2. The evacuation of the stomach is not accelerated, hence the
difficulty the stomach has in reaching its normal size.
3. The slight or negative result obtained by pyloroplasty in
obstruction from primary gastric atony compared to the posi-
tive results from posterior gastro-enterostomy.
Pyloroplasty is too dangerous in cases where there is exten-
sive induration of the tissues, much peripyloritis and adhesions
to liver, gall-bladder, colon, etc., and in cases of duodenal
stenosis.
It is indicated in cases of spasmodic stenosis and in slight
annular stenosis from ulceration accompanied by muscular hyper-
trophy.
Statistics. In the Hunterian Lectures I collected 318 cases of
pyloroplasty from all sources, of which 269 recovered, which
equals a mortality of 15.4 per cent. This included 14 cases of
the lecturers, of which 12 recovered, a mortality of 14.2 per cent.
As in the earlier operations, many were performed on cases that
would be now treated by gastro-enterostomy. The mortality
in properly selected cases should not exceed 5 per cent, at the
outside estimate, and of the 12 cases I have operated on since
1897 there is no fatality to record.
Case I. — March 9, 1895. Mrs. W., aged twenty-nine years. Had
"spasms" for ten years, but pain more on left side. Attacks two or
three times a week; start without apparent reason, last an hour or
two, but may persist twenty-four hours ; relieved by vomiting. Severe
cramps in legs ; loss of 2 stones in weight : no jaundice \ marked con-
stipation ; rigid right rectus; no rigidity, but tenderness to left ; dila-
tation of stomach well marked.
November 22, 1895. Relief under treatment, followed by relapse ;
now vomiting daily. Weight, 9 stone.
CHRONIC ULCER OF THE STOMACH. 2O3
Operation. Adhesions of pylorus separated. Active ulceration at
pylorus and tight stricture. Pyloroplasty (bone bobbin).
July 24, 1896. Weight, 9 stone 5 pounds. Very much better.
Relapse in 189S, possibly from recurrence of ulceration. I then per-
formed gastro-enterostomy. Quite well in 1900, and former weight
fully regained.
Case II. — January 13, 1897. Mr. M. B., aged fifty-two years.
Ulcer of pylorus, with stricture. Pyloroplasty. Bad health for twenty
years, with dyspepsia; worse since enteric fever, nine years ago. Last
two years much worse ; pain, sickness, and vomiting two to three
hours after meals, relieved by vomiting of large amounts; never
vomited blood ; loss of flesh. Weight, 9 stone 3 pounds. Emacia-
tion, dilatation of stomach; no tumor.
Operation. Stricture of pylorus. Pyloroplasty (bone bobbin used).
September 19, 1898. Dr. W. writes : "For some time little im-
provement ; stomach now works well. Looks better than I have ever
seen him."
Well February, 1901. Had gained normal weight.
Case IIL— March 18, 1897. Mrs. W., aged forty-six years. Stric-
ture, with active ulceration at pylorus Pyloroplasty. Gastralgia for
several years relieved by food.
In November, 1894, vomited dark fluid; since then frequent vomit-
ing ; longest interval two or three weeks. Pain in stomach, accom-
panied by hard lump, and often followed by vomiting. Great loss of
flesh and strength.
Operation. Pyloroplasty for contraction and thickening of pylorus ;
passage only admitted No. 2 catheter. Good recovery.
Well 1899. Considerable gain in weight.
Case IV. — May 24, 1897. Mr. H., aged thirty-nine years. Letter
dated May 13, 1897, to say: " During the last eighteen months I have
suff'ered much pain, which has caused me to be bedfast for two, three,
or four weeks at a time, and it has required another month or more for
me to gain strength enough to move about." Eighteen months ago
epigastric pain several hours after food ; relieved by vomiting. Since
then health never good. Three and a half months ago similar attack ;
very severe, with collapse. Vomit contained blood. Fourteen days
ago another severe attack. Normal weight, 10 stone 10 pounds;
now, 9 stone t,]4 pounds. Stomach ''weak" since childhood.
Marked dilatation. No tumor.
Operation. Deep ulcer at pylorus. Extreme stricture, barely ad-
204 R O B S O N ,
mitting ordinary director. Pyloroplasty (bone bobbin used). Com-
plete recovery from operation, and rapidly regained normal weight.
Letter dated February i6, 1898, to say : " I thought you would like
to know that I am able to attend to business as usual, and have done
so without interruption since July 19, 1897."
Case V. — July 12, 1S97. Mrs. W., aged forty-six years. Said to
have had ulcer of stomach twenty years ago. Since then subject to
attacks of pain one-half to two hours after food ; sometimes continu-
ous pain. For three or four months vomited three times a day. Lost
a stone weight in that time. Leading life of an invalid, and for a
long period under medical treatment without benefit. Dilatation of
stomach; visible peristalsis; tenderness over stomach, especially at
the pylorus. No tumor could be felt.
Operation. Stomach much dilated ; thickening at pylorus. Pyloro-
plasty (bone bobbin used). Good recovery.
January 8, 1898. Weighed 11 stone, a gain of over 2 stone.
Case VI. — July 27, 1S97. Mr. C, aged twenty-three years.
Vomiting and loss of flesh for two years. Once was 10 stone; now
is 7 stone in weight. Dieting and lavage gave only temporary relief.
Emaciation, pallor, and dilatation of stomach. No tumor.
Operation. Much-contracted pylorus; great hypertrophy, the walls
being more than one-third of an inch in thickness. Pyloroplasty, with
bone bobbin. Good recovery.
December 23, 1897. Weight, 9 stone 13 pounds. Well.
Case VII. — W. F., aged fifty-two years, had suffered from indiges-
tion for two years. This, however, had not interfered much with his
general health till the previous Christmas, when the indigestion was
accompanied every second day by acute pain and vomiting, coming
on about two hours after food. The vomited matter was in large
quantity, offensive, and sour, and at times coffee-ground in character.
From this time the patient became extremely weak and pale, and
rapidly lost flesh to the extent of i stone 7 pounds in five weeks.
He had pain on pressure over the pylorus; but no distinct tumor was
felt. There was marked dilatation of the stomach, and during the
attacks of pain it could be felt to harden under the hand.
On April 8, 1895, the abdomen was opened by an incision in the
middle line above the umbilicus, exposing the pylorus, which formed
a distinct tumor, adherent to and under cover of the liver, and which,
after being freed from adhesions to surrounding structures, was found
to be tightly strictured, so as only to admit the passage of a No. 12
CHRONIC ULCER OF THE STOMACH. 205
catheter ; the mucous membrane being extensively ulcerated, and the
walls thick and almost cartilaginous. The stricture was incised longi-
tudinally and sutured transversely over a bone bobbin by a double
row of sutures. The stomach was much dilated and atonic. Though
the pyloric tumor gave rise at the moment to a suspicion of cancer,
there was no evidence of growth, and the glands were not affected.
October 30, 1S96, he called to report himself, looking robust and
well. He had gained 3 stone in weight since his operation.
Gastroplasty is an operation that I have successfully employed
in a number of cases of chronic ulcer leading to hour-glass
stomach. It consists in making a longitudinal incision through
the strictured part of the stomach and bringing the edges of the
wound together transversely, thus obliterating the stricture.
A convenient method of performing the operation is by the
use of a large decalcified bone bobbin as described in the cases
appended. If the strictured part of the stomach be actively
ulcerating the ulcer must be excised at the same time, other-
wise subsequent contraction may occur, or possibly the ulcer,
already chronic, may persist and lead to a continuance of the
symptoms; in such a case, if excision be impracticable, gastro-
enterostomy must be performed, or if the pylorus be free from
disease the operation oi gastrogastrostomy may be done in order
to short-circuit the constriction,
I have operated on 13 cases of hour-glass stomach due to
chronic ulcer, with 12 recoveries. The following are good
examples :
Case I. — M. B., aged twenty-nine years, gave a four-years' history of
ulceration of the stomach, with vomiting of blood on one occasion, and
the presence of melaena several times. As the pain was always easier
when the patient was lying on the back, an ulcer on the anterior sur-
face of the stomach was diagnosed.
This was confirmed at the operation, as the anterior wall of the
stomach was so puckered that the cavity was divided into two, which
were connected by a narrow channel, which was laid open by a free
longitudinal incision, in which was laid a large bone bobbin, the
wound being then brought together transversely over it, thus leaving
a channel of nearly two inches between the two cavities. The patient
2o6 ROB SON,
went home within the month, and has completely recovered her health
and strength.
Case II. — Mr. D. M., aged forty-four years, admitted with well-
marked dilatation of the stomach, and a history of twenty years' gas-
tric trouble.
The constriction in this case was two and a half inches from the
pylorus, the cavity between the stricture and the pylorus being very
much smaller than the proximal one. The treatment was by gastro-
plasty over a large bone bobbin.
Recovery was delayed by an attack of pleurisy, but the patient is
now quite well, and has gained rapidly in weight.
Case III. Double hour-glass contraction of the stomach. Gastro-
plasty and gastrolysis. — Miss M. P., aged thirty years. There had
been attacks of pain and vomiting for fifteen years. The pain began
at the left side and passed to the epigastrium and through to the left
subscapular region. There had been severe haematemesis ten years
before. Occasionally, both before and since, the vomit had been
streaked with blood, which was sometimes "coffee-ground," but it
had contained no large quantity of blood for eight years. The patient
vomited large quantities at times and had lost flesh steadily for the last
five years. There were dilatation of the stomach and peristalsis. No
tumor could be felt, but the pylorus was felt to harden from time to
time.
Operatio7i, June 6, 1899, at a surgical home in Leeds. Double-
hour glass contraction discovered. One-third of the distance from the
cardiac extremity adhesions caused a marked diminution of calibre,
and two inches from the pylorus a contraction only admitting the tip
of the little finger was found. The adhesions were divided and gas-
troplasty was performed, the wound being sutured over a large bone
bobbin.
After-history. — The patient made an uninterrupted recovery, and
in two months she had gained 2 stone in weight.
Case IV. Extreme hour-glvs contraction. Gastroplasty. — Miss M.
D., aged forty-eight years. The patient had had constant indigestion
and flatulence for twenty years, with a feeling of pulsation and tender-
ness at the epigastrium. There had been free hsematemesis two years
before and vomiting occasionally since, but lately the patient had
ceased to take much solid food. She had noticed slime and blood
in the motions, possibly due to constipation, which was extreme.
There had been great loss of flesh. No tumor was present, but there
CHRONIC ULCER OF THE STOMACH. 20/
was tenderness in the epigastrium and a well-marked splash on succus-
sion.
Operation, July 28, 1899. Extreme contraction one-third way from
pylorus, just admitted tip of little finger. Gastroplasty was performed,
a large bone bobbin being used.
After-hislory. The patient made a good recovery from the opera-
tion and the indigestion was relieved. There was an increase in
weight of about a stone, and improvement in the general health, but
the stomach remained dilated, and she continued anaemic and weak ;
this was at first thought to be due to bleeding from piles, but after they
had been ligatured the weakness still continued, and, although there
was no vomiting, flatulency and discomfort after meals, with loss of
appetite, led to a suspicion of recurrence of disease in the stomach,
which on being distended with CO, reached three inches below the
umbilicus, and on being washed out after a test-meal showed impaired
motility.
January 24, 1901. The abdomen was 6pened again through a
medium incision above the umbilicus, when marked dilatation of the
stomach was seen, with contraction and some thickening over the
pylorus ; but where the hour-glass contraction had been operated on
eighteen months previously, it was interesting to note that neither scar-
ring nor contraction was seen, and it would have been impossible to
tell by naked-eye appearances that anything had been done.
A posterior gastro-enterostomy was performed, a bone bobbin being
employed. Recovery was uninterrupted, and before the patient left
the home, at the end of the month, she was taking ordinary food with
relish and without any discomfort. She had then gained several
pounds in weight.
Adhesions of the stomach to adjoining organs are so common
in chronic stomach ulceration that gastrolysis, or the detaching
or otherwise treating bands and short adhesions to adjoining
viscera or to the abdominal wall, is performed in by far the
greater number of cases. Such adhesions are frequently the
only remnants of ulcers that have healed ; at other times they
have been left by perforation of the stomach wall by an ulcer,
from the direful consequences of which they have saved the
patient. In many cases they give rise to symptoms resembling
ulcer, though the adhesions may be due to causes such as gall-
208 ROBSON,
stones outside the stomach itself; in such cases the operation
of gastrolysis may be entirely curative.
I have performed gastrolysis in 56 cases, all of which have
recovered. The following case is given as an example:
Gastrolysis for adhesiofis cmised by chronic gastric i/lcer. — Miss
M. B., aged forty-two years. Twenty-two years ago symptoms of ulcer
of stomach. Since then has suffered from vomiting attacks every week
or two, and from pain after food. During the last three years symp-
toms more marked. Under medical treatment, with rest in bed ; no
improvement. Vomit large in quantity and fermenting, sometimes
containing blood. Loss of weight to the extent of three stone. Great
tenderness over stomach, especially to the left. Stomach dilated,
reaching below umbilicus and well over to the right.
Operation. On anterior surface of the stomach scar of an old ulcer
is visible. Lesser curvature of the stomach, closely adherent to the
liver. Pyloric extremity and first part of duodenum attached to gall,
bladder and cystic duct. Adhesions separated and omentum inter-
posed between pylorus and gall-bladder.
After-history. Perfect recovery. March 7, 1900, can eat any-
thing without discomfort, and is rapidly putting on flesh. Has gained
20 pounds since her operation. March, 1901, quite well] had gained
over 2 stone in weight.
Many other examples of gastrolysis could be given where
the benefits derived from operation have been quite as great.
Pylorodiosis, by which name is understood the operation of
stretching the pyloric sphincter, either by means of the fingers
invaginating the stomach wall, when it is known as '^ Hahn's
operation," or by digital or instrumental stretching after having
made an opening into the stomach, when it is known as " Lo-
retta's operation," is a method of little practical value in the
treatment of ulcer ; and in some of the cases where I performed
the operation, though the immediate results were good, relapses
subsequently occurred. If performed by invagination without
opening the stomach cavity, it is an operation unattended by
risk. It may possibly be of service in simple spasm of the
pylorus, but I have not much faith in its effects being lasting.
Did time permit, it would be easy to give from my own
CHRONIC ULCER OF THE STOMACH. 2O9
experience examples of operations for all the complications
of gastric ulcer that I have mentioued, and, as many of the
cases are of great individual interest, I think they would have
proved interesting to my audience, but it is quite impossible to
do more than to refer to them unless I am to occupy the whole
of the afternoon, and this I have neither the desire nor the in-
tention of doing.
I will, however, mention the results of my experience in
operations for simple diseases of the stomach out of over 200
operations that I have performed.
In 56 cases I have performed gastrolysis for the separation of
adhesions which were producing disabling conditions, all the
patients recovering. In 13 cases I have operated for hour-glass
stomach due to ulcer, 12 of the patients recovering and being
now well.
In 6 cases I have operated for hsematemesis, with 5 recov-
eries ; in 4 cases for fistula, due to chronic ulcer, all the patients
recovering.
Of the 18 cases in which I have performed pyloroplasty, 16
have recovered, the two deaths being in the earlier cases, one
being due to perforation in the second week after operation.
Of the posterior gastro-enterostomies previously referred to
for simple diseases of the stomach, in 40 cases there were two
deaths, both due to accidental causes, one being pneumonia in
a phthisical patient.
Of the anterior gastro-enterostomies, including cases operated
on ten years ago, in 19 cases there were four deaths, one from
an accident at the time of separation of a Murphy's button, one
from shock in a patient very exhausted at the time of operation
(Senn's plates being used), one from perforation of an ulcer on
the twelfth day, when apparently convalescent, and one from
peritonitis extending from the abdominal wound.
Of the 2 gastroplications, both recovered.
Of the 3 cases of pylorodiosis, all recovered.
In 8 operations for perforating gastric ulcer, there were two
deaths, directly following an operation in cases treated when
peritonitis was general.
Am Surg 14
2IO ROBSON,
Of the 6 cases in which I directly excised a gastric ulcer,
or ulcers after opening the stomach by gastrotomy, all re-
covered.
Of I case of gastrotomy for the removal of foreign bodies
and I for perforating wound of abdomen, with haematemesis,
both patients recovered.
It will be seen that out of 177 operations for simple diseases
of the stomach, including cases of perforation and hemorrhage,
165 patients recovered, or 93.2 per cent.
Method of Employing and Suggested Advantages of Using
the Developed Bone Bobbin.
In the course of my paper reference has been made to a
method I have been systematically pursuing since 1891, not
only in stomach operations, but in nearly all the operations
which involved the making of an anastomatic opening between
the hollow viscera — I mean the method of suture over a decal-
cified bone bobbin.
I have adopted it in a very large number of cases and in a
great variety of operations, and as a result of this extensive
experience I am more than ever convinced that it is a reliable
procedure which I can thoroughly recommend to others. It
is more easily demonstrated than described, and at the end
of this discussion, or at such other time as it may be desir-
able, I shall be pleased to show the method either on the
cadaver or on a model. It is really very simple, and only
involves two continuous sutures, one of chromicized catgut to
unite the mucous margins of the two openings, and one of cellu-
loid thread to unite the serous surfaces about a quarter of an inch
away from the new opening. Pagenstecker's thread or spun
celluloid has replaced silk in my practice, it being stronger,
easily sterilized by boiling, and less absorbent.
The bobbin, which is made for me by Messrs. Down Bros.,
of London, in various sizes, from the small one required for
cholecystenterostomy or for the union of the small viscera of
children, to the large one employed for gastroplasty, or for the
CHRONIC ULCER OF THE STOMACH. 211
end-to-end union of large intestines in the adult, is nothing
more than a cylinder of decalcified bone with raised ends, which
is placed in the new anastomatic opening around which the
sutures are applied.
The advantages claimed for the method are:
1. That it secures the opening, being of the exact size in-
tended, and that there is no possibility of the passage being
made too small by the drawing up of the sutures before the
knots are tightened.
2. That it secures an immediately patent channel between
the two anastomosed viscera.
3. That the bobbin protects for from twenty-four to forty-eight
hours the new line of union from pressure and from the irrita-
tion of the visceral contents.
4. That it facilitates the application of the sutures, and so
adds to the expedition of union by sutures.
5. That no foreign material is left in the alimentary canal
which may irritate or cause subsequent trouble, for the bobbin
rapidly dissolves in the alimentary juices.
6. That the method has now been proved by ample experi-
ence to be rapid, easy, efficient, and safe.
For stomach operations it is used in gastro-enterostomy,
in pyloroplasty, in gastroplasty, and in pylorectomy, or par-
tial gastrectomy, and in the latter operation it is unnecessary
to use more than two continuous sutures for the whole opera-
tion.
In adopting the method, it is convenient to begin with the
serous suture, which is applied around the posterior half of the
circle, the needle still threaded is then laid aside till the final
stage; the openings into the viscera are then made, and any
redundant mucous membrane cut away; the mucous suture is
now applied, uniting the posterior half of the circle ; the bone
bobbin is now inserted, and the mucous suture continued around
the anterior half-circle until it reaches the point where the
mucous stitch was begun and where the loose end will be found,
these two ends are then tied firmly ; the serous suture pre-
viously laid aside is now picked up and continued around the
212 ROBSON,
anterior half-circle until the loose end of the celluloid thread
is reached, when the two ends are tied firmly.
The two hollow viscera are now united by a hollow cylinder
of decalcified bone surrounded by two continuous threads, one
uniting the mucous margins and one the serous surfaces about
one-fourth or one-third of an inch away from the anastomatic
opening.
CHKONIC ULCER OF THE STOMACH. 213
DISCUSSION.
Dr. William J. Mayo, of Rochester, Minnesota.
I will confine my remarks to the question of gastro-enterostomy in
the treatment of open ulcer of the stomach. Excision or other form
of surgical treatment is indicated in a few cases presenting special
features ; but the common situation of the ulceration, its varying ex-
tent and the reasonable possibility that more than one ulcer exists,
makes gastro-enterostomy the practicable operation in the majority of
cases. Not infrequently the site of the ulcer cannot be discovered,
rendering gastro-enterostomy the operation of necessity.
The symptoms of ulcer of the stomach depend somewhat upon the
situation of the disease. Ulcer is most common near the pylorus, a
position which may introduce certain mechanical features, and it is
in the relief of these secondary phenomena that this operation achieves
its triumphs. Gastro-enterostomy relieves the' hyperacidity and allows
prompt emptying of the ingesta, preventing irritation and aiding
nutrition.
The ulcerated stomach is often contracted, and among the earlier
writers it was supposed to be always small ; this is but part of the
truth. In acute ulcer it is small, and if the ulcerative process is not
in the vicinity of the outlet it will probably remain small. On the
contrary, it is during the healing process that many ulcers in the
pyloric region become most troublesome. Ulcers in this situation are
often extensive, and in chronic cases, perhaps, but partly cicatrized.
Enough distortion or narrowing of the pyloric outlet takes place to
materially obstruct the opening, the unhealed portion of the ulcer
keeping up irregular symptoms of its presence in addition to the dila-
tation. In such cases symptoms of open ulcer alternate with periods
of health, and later signs of ulcer in a stomach more or less dilated
supervene. The majority of cases when once cicatrized remain
healed, but a minority occasionally lapse into open ulcer. The ca-
pacity of the stomach affected by ulcer is not greatly changed in the
majority of cases, but if so it has a surgical significance. This gives
us a good working basis for comparison. First, ulcers in the pyloric
region, with a normal or enlarged stomach, and, second, ulcers in a
contracted stomach.
As to the first group, gastro-enterostomy is the operation of choice.
It delivers the ingesta at a point sufficiently remote from the disease
214 DISCUSSION.
to prevent irritation, and the healing process is not interfered with, so
that it progresses rapidly. The relief to the mechanical obstruction
is immediate and satisfactory. We have made gastro-enterostomy five
times for this condition, and all were speedily cured and remained
cured. At times a small ulcer at the pylorus causes pyloric spasm,
and symptoms are produced resembling mechanical interference. In
four operated cases of pyloric spasm we found dilatation only once,
and then not at all marked. In this form of disease pyloroplasty is
fairly effective, but does not compare to the benefits derived from the
gastro-enterostomy in suitable cases, although the division of the py-
loric sphincter stops the spasms, and the enlargement of the opening
exerts a healing influence on the ulcer.
Gastro-enterostomy on the small stomach affected by ulcer does not
give immediate relief as a rule, and in three cases of our own the symp-
toms in a modified degree continued for some months. However,
experience goes to show that after gastro-enterostomy the ulcer will
eventually heal, but the results are not as good as in the former class
of cases. The pylorus being open and the stomach small, it is self-
evident that the main function of gastro-enterostomy is already well
performed, and it is probable that in some cases the artificial opening
will not remain patent. The majority of dilated stomachs are due to
old ulcers which have permanently closed, and only the mechanical
interference with the progress of the food remains.
As to gastro-enterostomy we have made sixty-one for all purposes,
using the Murphy button and uniting the jejunum to the anterior
wall of the stomach as near the greater curvature as possible. So far
as I am able to ascertain, this operation is equally as good as the pos-
terior, and easier of performance. By getting the opening well at
the bottom of the stomach pouch and near the greater curvature
there is little tendency to regurgitant vomiting, gravity aiding the
downward progress. Three-fourths of our own cases have been oper-
ated on for the relief of non-malignant disease, largely pyloric ob-
struction, the result of healed ulcer, with but one death in over forty
cases. In the malignant cases the death-rate was over 25 per cent.
Dr. William L. Rodman, of Philadelphia.
I very much enjoyed the paper of our distinguished guest, and am
very certain that everyone present did also. His name has so long
and so intimately been associated with this work that his utterances
are necessarily ex cathedra.
CHRONIC ULCER OF THE STOMACH. 215
I fully agree in what he says about partial gastrectomy, as it is only
applicable to a certain percentage of cases. It is almost entirely a
question of location of the ulcer. If it be situated anteriorly and
reasonably free from adhesions, partial gastrectomy has been shown
to be, as Mr. Robson states, practicable and safe. Forty cases that I
collected from private correspondence a year ago gave a mortality of
15 per cent. If the ulcer is situated posteriorly, where the adhesions
are likely to be intimate and dense, excision becomes impracticable
in many instances. We should not forget that a very great majority
of ulcers are situated posteriorly, and, therefore, cannot be treated
by partial gastrectomy. I also am in accord with the position taken
by the distinguished essayist, and congratulate him upon his own suc-
cess in the treatment of these cases. I am glad to hear him state that
he has become aggressive in the treatment of hemorrhage. While it
is usually a mistake to operate during or subsequent to the first hem-
orrhage, as soon as the recurring nature of the hemorrhage has been
manifested delay is dangerous. A careful study of all published cases
permits no other conclusion to be drawn, and it is my judgment that
we will become even more aggressive than formerly in the treatment
of gastric hemorrhage.
Dr. Robson, I have nothing more to add, except to say that I
have never had the pleasure of seeing the elastic ligature employed.
I desire to thank the members of the Association and the speakers for
the kind interest they have taken in my paper.
EXHIBITION OF METHODS OF MEDICAL INSTRUC-
TION IN THE JOHNS HOPKINS MEDICAL
SCHOOL AND HOSPITAL.
Dr. H. a. Kelly then addressed the meeting upon the " Necessity
of Employing the Newer Methods of Diagnosis in Rectal and Urinary
Diseases," followed by a practical demonstration. He spoke as
follows :
I have catheterized the ureters constantly for the past thirteen years,
some thousands of times, and have so repeatedly demonstrated the ease
with which this method of investigation can be employed, that it
is a source of no little chagrin to me to see the various complicated
apparatuses which have been devised and recommended from time to
time for this purpose.
To demonstrate once more the extreme simplicity and feasibility of
my procedure to this society, I now bring before you a patient whom
I have never seen or examined before. As you observe, I pass in a
simple cylindrical vesical speculum, the bladder at once becomes dis-
tended with air, the ureteral orifices are now exposed by reflected
light, and without the slightest difficulty or hesitation I am at
once able to expose and catheterize the ureter ; as the catheter enters
the ureter and is splinted by the embracing ureteral wall, it is stripped
off from the wire stilette which stiffens it on the outside and so prevents
any coiling up in the bladder.
The whole procedure, as you see, is, I say again, an extremely simple
one ; the difficulties which embarrass the beginner, but are easily over-
come, are these: In the first place, the bladder does not always expand
well ; the fault then lies in the posture of the patient, who is always in
the knee-breast position. If the examiner or a skilful nurse will see
that the patient is as low down on the table in front as possible, with
the side of the face touching the table, while the thighs are vertical,
this difficulty will disappear.
METHODS OF MRDICAL INSTRUCTION. 21/
The second great difficulty is that examiners search for the ureteral
orifices by introducing the end of the speculum too far into the blad-
der. The way to avoid this is to withdraw the speculum until .the
internal ureteral orifice just begins to close over the end, and then to
push it in about i cm. and 30 degrees to the right or to the left ; the
ureteral orifice then appears as a little slit on the urethral side of a
slight eminence which I have named the mons ureteris.
In a nulliparous patient it is always necessary as a preliminary step
to let air into the vagina in order to drop the base of the bladder to
the plane of vision.
This method of vesical and ureteral examination is of extreme value
in treatment as well as diagnosis. I probably find more satisfaction
from its use in the diagnosis ard treatment of the various forms of
cystitis than in any other field. I recall, as I speak, three cases of
cystitis, accompanied with extreme suffering, in each of which the
patients had had prolonged treatments, and were utterly miserable
with their sufferings, and in a wretched state of health. Within five
minutes of the time when I first saw them and took them into the
examining-room my speculum was introduced, and I discovered in
each of the three a stone in the bladder, the simple and easily remov-
able cause of the disease. I have had between 150 and 200 cases of
cystitis within the past five years, many of which I never would have
been able to have handled at all without first making a careful exam-
ination by means of inspection, and then following this up by regular
topical treatments of the affected vesical areas just as one would treat
an ulcerated sore- throat.
It gives me great pleasure to demonstrate also to the society my
method of investigating diseases of the rectum and sigmoid flexure
through my tubular specula, of which I have now between forty and
fifty sizes constructed for the most part for strictures of various calibres.
Under such a method of examination, easily conducted as you see,
the entire rectum balloons out and is freely opened to inspection.
Ulcerations may in this way be found and treated topically with
stronger solutions than we would dare to inject in the bowels with a
syringe. I also often pack long strips of medicated gauze high up
into the bowel, filling it and distending it, or pledgets of cotton
saturated with ichthyol or other solutions.
In the case of a distinguished colleague who had suffered exces-
sively from previous examinations, and in which decided differences
of opinion had been expressed as to whether there was or was not any
2l8 METHODS OF MEDICAL INSTRUCTION.
disease of the bowel to account for an obstinate constipation, by
means of this tubular inspection, in the knee-chest posture, without
producing the slightest discomfort, I was able to expose to view an
extensive adenocarcinoma high up in the rectum, and with these long
alligator forceps to remove a piece of tissue without his knowledge,
sufficient to show the nature of the disease.
I would like to emphasize and insist upon the fact that if this
method of diagnosis is used in all cases supposed to be suffering from
a more or less chronic "mucous colitis" or "enteritis," the gratifying
discovery will be made in a large number of cases that the disease is
a purely local one, limited often even to the lower rectum, and that
sound bowel is within easy reach through the spectrum, and that an
obstinate affection of years' standing now becomes amenable to appro-
priate local treatments.
Dr. Hugh H. Young spoke on the subject of " Catheterization of
Ureters in the Male."
After showing the instrument which he preferred, viz., the latest
model of Casper, a male patient was brought in prepared for cys-
toscopy by previous injection of cocaine into the urethra, and the
bladder then filled with salt solution.
The case proved to be a favorable one, and both ureters were
readily catheterized in succession and the instrument withdrawn,
leaving the catheters in the ureters.
Dr. Young then exhibited a collection of cystoscopes, showing the
history of ureteral catheterization.
The first instrument was that devised by Brenner in 1888, but
which proved unsuccessful in his hands. It was not until 1893, when
James Brown, of the Johns Hopkins Hospital, modified Brenner's
technique by employing a steel stilette for his catheter, to give it the
proper angle, that the practical value of Brenner's instrument was
demonstrated, and the male ureters catheterized for the first time.
Brown published in \.\\q Johns Hopkins Hospital Bulletin five cases in
which he had been successful.
Following this various instruments have been brought out by Nitze,
Casper, and Albarran, all of whom made subsequent improvements
and modifications.
At present there exist several instruments with which the male
ureters have been successfully catheterized, but the difficulty with all
METHODS OF MEDICAL INSTRUCTION. 219
of these except Casper's is that it is practically impossible to with-
draw the instrument without pulling out the catheter from the ureter,
and that only one ureter can be catheterized at a sitting. In the in-
strument of Casper, however, this is not the case, as after the cathe-
terization of one ureter, the catheter can be immediately thrown out
of the instrument by the withdrawal of a slide which covers the
channel of the catheter.
After reinsertion of this slide the instrument is ready for the cathe-
terization of the second ureter, when, by again drawing out the slide
and dislodging the other catheter, the instrument can be readily re-
moved without drawing the catheter out of the ureters.
As it generally requires more than thirty minutes to collect sufficient
urine, the ability to withdraw the instrument, leaving the two catheters
in situ, is at once apparent.
"Laboratory Methods of Teaching " was the subject of remarks
made by Dr. William H. Welch, who spoke as follows :
The value of laboratory methods of teaching is now so generally
recognized that it may not be out of place to speak of some of their
shortcomings. They are extremely time-taking, and are not adapted
to present the entire contents of any subject. Their great service is
in developing the scientific spirit and in imparting a living, abiding
knowledge, which cannot be gained by merely reading or being told
about things. So important are these ends, that it seems difficult to
overestimate the value of the laboratory in scientific teaching. But
there are aspects of every subject, even of such best fitted for labora-
tory instruction, which it is important for the student to learn, but
which, either from lack of time or from the nature of the subject-
matter, cannot readily be taught in the laboratory. The attention of
the student in the laboratory is likely to be concentrated upon isolated
facts, especially those most susceptible of easy demonstration to classes,
while other groups of facts and particularly broad general principles
are in danger of being lost to view. There is, therefore, risk of loss
of perspective in relying solely upon instruction in the laboratory.
Hence, I have found it desirable to supplement the laboratory work
by didactic and demonstrative lectures. Recitations are also valuable
in systematizing the work of the student, in rendering his knowledge
more precise, and in affording opportunity to the teacher to clear up
difficult or obscure points.
220 METHODS OF MEDICAL INSTRUCTION.
The methods of instruction followed in any particular department
are left with us practically, to the discretion of the head of that de-
partment. Some give no didactic lectures, others give a few, and still
others make more extensive use of them. If a teacher is convinced
that didactic Icctur'es are useless, it is not likely that his lectures will
be of much value, and it may be as well for him to dispense with them.
Our first two years of instruction are devoted to the fundamental
medical sciences, and during this period most of the teaching is in
the various laboratories. Near the end of the second year the students
are taught the methods of normal physical diagnosis, so that they are
prepared to take up at the beginning of the third year the clinical
study of disease. During the last two years the dispensary and the
wards of the hospital occupy the same relative position in the scheme
of instruction as do the anatomical, physiological, pathological,
and other laboratories in the earlier period. We have found great
advantage in the establishment of clinical laboratories, where, during
the clinical years, the students are thoroughly trained in the applica-
tion of microscopical and chemical procedures to the diagnosis and
clinical study of disease. These technical procedures can be taught
best by those frequently engaged in using them, and at a time when
the student can appreciate their importance; and it is a great relief to
the courses in the earlier years, particularly those in bacteriology and
pathology, to be freed from the necessity of including these practical
topics.
Every student during each year of his medical course is obliged to
have a microscope, and if he does not own one, he rents one for a
price which covers the interest on the investment and repairs. This
microscope is his property for the year ; he uses it in different courses,
and he can take it to his home. The laboratories are open to the
student throughout the day, and he can spend his spare time at his
desk.
Any student who chooses to take up some small piece of original or
advanced work is encouraged to do so, for the educational value of
such work is very great. The number of those who have real capacity
for independent research and the creative faculty is, of course, small,
but it is of the highest importance to recognize and encourage this
rare talent when it exists.
Our pathological laboratory was in operation before the establish-
ment of the hospital, and both were active before the opening of the
medical school. This resulted in the establishment of an unusually
METHODS OF MEDICAL INSTRUCTION. 221
close relationship between the work of the laboratory and that of the
hospital, which has been of great mutual advantage. From the start
the pathological service has been recognized as an integral and essen-
tial part of the hospital, co-ordinate with the clinical services. We
have pathological internes ranking with the clinical internes, and it
cannot be doubted that this arrangement has greatly promoted the
scientific work of the hospital and given to it one of its most distinc-
tive features.
We have tried to keep in view that it is the function of a great
medical school not only to teach, but also to advance knowledge.
In the selection of teachers for this double function it is as important
to consider their productive capacity as their powers of imparting
knowledge, and I do not think it happens as often as is sometimes
represented that a fruitful investigator is not at the same time a good
teacher.
There is one inquiry which I should especially like to bring before
this body of leading surgeons of this country, and that is whether the
opportunities for training and advancement in clinical medicine and
surgery in this country have kept pace with the progress of medical
science in the same measure as have those open to young men seeking
the higher careers in anatomy, physiology, pathology, and the other
more purely scientific branches of medicine? The laboratory side of
medical teaching has now, I believe, in our leading medical schools
advanced from the weakest to the strongest feature of our curriculum,
and if after graduation a young man chooses for his career one of
these scientific branches, he can find the opportunity to secure an ex-
cellent training in this country, and after serving as an assistant in a
laboratory, and winning a reputation by his published work, he can
look forward to securing a desirable position as head of a laboratory.
For such positions our schools seek the best men wherever they can
find them, and are not limited to the choice of home talent.
Are there similar opportunities for prolonged, thorough training in
clinical medicine and surgery after graduation and for promotion ?
We afford such an opportunity here to a few men who are fortunate
enough to secure the more permanent resident positions over the
regular internes, but in general the hospitals of this country are so
organized as not to offer like opportunities to those seeking the higher
careers in medicine and surgery. In consequence of what I believe
to be a defective organization of our hospitals, the young clinician
with high aims does not find opportunities for acquiring experience
222 METHODS OF MEDICAL INSTRUCTION.
and making a reputation analogous to those available to anatomists,
physiologists, and pathologists. Did time permit, it would not be
difficult to show that the work of the hospital also suffers thereby.
Furthermore, what chance is there that a man who has made a high
reputation in clinical medicine or surgery in one place will be called
to a desirable position elsewhere? In consequence of the relation
usually existing between our hospitals and medical schools, and for
other leasons, our schools restrict themselves to the selection of local
physicians and surgeons for their important clinical chairs to a much
greater extent than in the choice of anatomists, physiologists, and
pathologists. Hence it is that clinical medicine and surgery in their
higher fields do not offer to young men the opportunities and attrac-
tions in this country which they should do, and which they do in
Germany and some other foreign countries.
In conclusion, I beg to say that our laboratories are open for your
inspection, and we shall be glad to see any of you there. We have
had no money to put on external adornment, but we have a very fair
equipment for actual work and good facilities for instruction.
PHLEBITIS FOLLOWING ABDOMINAL OPERATIONS.
By albert VANDER VEER, M.D.,
ALBANY, N. Y.
The great field of abdominal surgery has been so carefully
and thoroughly investigated, the operative technique perfected
to such an extent, the many favorable recoveries, and fatal
cases looked into with such earnestness, that we go on doing
operations with perhaps as little strain and anxiety as used to
present to the operating surgeon in much less serious surgical
work, yet occasionally some unlooked for complication will
arise. When this occurs our anxieties begin, and we are led
to wonder as to the etiology that is bringing our patient more
prominently in sight as a subject for further study and investi-
gation.
There are times when, as regards my own experience, I
approach my cases with greater fear as to favorable results than
at other periods. There are occasions when I look for a more
serious type of lesions in the same relative class of cases. My
abdominal work during an epidemic of grippe has often given
me much greater care and anxiety than when these atmospheric
conditions did not prevail. I am sure that in my work in
appendicitis I have been led to look upon the months of August
and September as bringing to me a greater number of cases, and,
more particularly, of the acute, fulminating or perforating form,
because of the diet that young people indulge in at that time.
Also during the months of December and January, when more
active exercise is being indulged in — skating, tobogganing
or coasting — the out-door exposure being greater for young
people at this period; but not until recently, and in a compara-
tively short time, have I had that rather startling symptom,
224 VANDER VEER,
that to the obstetrician is alarming, and to the operating surgeon
not at all comforting, i. e., phlebitis. Within the past two years I
have had four cases, and of such a nature that I feel them worthy
of report. We really meet with so few post-operative complica-
tions in our abdominal work at the present time, and are so
hopeful of quick return to health, that we are, perhaps, at times
rather buoyant in our encouragement to patients and their
friends as to immediate recovery.
When doing serious abdominal operations, particularly when
working deep down in the pelvis, and when ligating the uterine
and ovarian vessels, and, as is sometimes the case, perhaps when
there are many adhesions present, a mass ligature is applied,
I have often wondered that we did not get thrombosis and more
dangerous complications of the venous circulation than one
meets with or hears of as the experience with other operators.
I can call to mind but one fatal case of pulmonary thrombosis
following this class of operations, and when my attention was
called to the first of the cases, to which I am about to refer, I
was alarmed and disturbed, fearing our technique had failed us
in some way, the fault being either in the neglect of proper
attention to the alimentary tract before the operation, or that,
perhaps, the ligature had been improperly applied, or possibly
infected in itself. One may reason clearly and impartially as
to a complication of this kind, but notwithstanding your firm
belief in your preparation of patients by a nurse in whom you
have all confidence, or in your operating-room nurse, who has
conducted skilfully and intelligently the preparation of ligatures,
sterilization of instruments and water, gauze, sponges, etc., yet
a disagreeable suspicion enters your mind of sepsis. You feel
at once like charging somewhere along the line the entrance of
this element in disturbing the usual recovery of the patient,
who has been promised much, but delayed, at least, to weeks of
additional treatment. In your mind is the constant fear of some
sudden death, such as one who has had any great obstetrical
practice in earlier life calls to mind as the result of thrombosis
from the puerperal infected uterus.
I say these are the thoughts that come to one, and yet when
PHLEBITIS FOLLOWING ABDOMINAL OPERATIONS. 225
we consider the great range of pathological lesions met with in
the pelvis, and that are now treated so intelligently and success-
fully, I do not know that we ought to be much surprised in hav-
ing these complications of venous thrombosis ; however, in my
own experience, as I have stated, and in my reading and recol-
lection of personal conversation with professional friends, these
cases are certainly rare. It is not pleasant to promise a patient
that they are to be well of their operation within a stated period,
and then have that time doubled, or increased threefold, as I
am sure has been my experience in these cases of phlebitis, and
where we feel it is absolutely necessary to keep the patient quiet
long enough, so that there may be no blood-clot carried into the
circulation to be followed by a sudden and unexpected death.
The following cases are reported because I believe them to
be rare. I have nothing to add to what has already been hinted
at as regards the pathology. In the summing up of the treat-
ment possibly nothing new, rather a judicial presentation of
what is rational, calm, and well understood.
It will be noted that these cases come somewhat near each
other, and immediately after moving into a splendid new hospital
plant, and beginning our work. Our other operations of every
kind were doing well, and every usual precaution had been
exercised.
Case I. — Mr. H. N. S., aged fifty-eight years, for nearly a year had
suffered from gradual enlargement of the liver, and who permitted an
exploration on April 12, 1900. The growth was found to be an angi-
oma in connection with the lobus spigelii. This was removed by
Dr. Macdonald and myself. The tumor rather larger than my first.
Wound closed by layer sutures. Patient progressed very favorably
until April 26th, when he developed marked symptoms of phlebitis in
the left leg. No especial tenderness in the pelvis, nor about the ab-
dominal cavity. The swelling continued for a long time, although
this patient was under a similar line of treatment afterward pursued
in the other cases. Ultimately the oedema and swelling disappeared,
but the patient was over three months in regaining the entire use of
his leg. Although the disease of the liver has returned in this case,
the patient at the present time shows no redema or any complication
of the venous circulation.
Am Surg 15
226 VANDER VEER,
Case II. — Mrs. A. F. C, aged forty years, referred to me by Dr. J.
M, Bigelow, with a history of a gradually increasing enlargement of
the abdomen. Patient gave a very good family history, but had lost in
flesh during the past year, and now presented the marked look of suf-
fering that accompanies ovarian disease. Patient married several
years ; never pregnant ; menstruation somewhat irregular, and some-
what profuse at times ; urine normal ; condition of bowels not well
defined. On examination she presented the appearance of a multi-
locular ovarian cyst.
Operation May 20, 1900. It was found to be a case of double ova-
rian tumor, one from each side, but with scarcely any adhesions and
no great embarrassment during the operation. Each pedicle secured
by silk ligature, and the peritoneal surface stitched over with very fine
silk.
Bowels were thoroughly emptied previous to the operation ; a good
movement secured at the end of the second day, and the patient went
on progressing as favorably as one could wish, giving no anxiety to
nurse or myself. About the twelfth day she complained of pain in the
left leg, which I was inclined to attribute to the position she had been
in — resting on that side, and thought at first it might be a rheumatic
condition. I am frank to confess that I did not grasp quickly the pos-
sibility of circulatory complications ; but at the end of forty-eight
hours the pain had increased to such an extent that the inability to
move the limb, the rise of temperature, with slight increase of pulse
rate, led me to make a more careful examination, and, not finding any
complication within the pelvis by bimanual search, I was forced to
recognize a condition of phlebitis implicating the femoral vein, the
external saphenous, and the veins of the calf of the leg, the latter
being very sensitive to the touch. Patient's bowels were promptly
emptied by the use of calomel and salines, sufficient codeine given to
afford relief from the pain, carbonate of ammonia administered,
together with diuretics, as the secretion of urine was not very free,
and the limb wrapped in cotton and oil silk, absolute rest being en-
forced. While her convalescence was delayed fully three weeks, yet
this patient made a good recovery, with no permanent disability, the
anxiety of her case, however, being as great as any I have had. The
husband being an intelligent man, and knowing the danger of throm-
bosis in connection with phlebitis, gave us no little amount of trou-
ble in his inquiries and expression of fears as to sudden death. At
the present time this patient presents a picture of absolute health,
PHLEBITIS FOLLOWING ABDOMINAL OPERATIONS. 22/
scarcely to be recognized as the case upon whom we operated a year
ago.
Case III. — Mrs. J. N., aged forty-four years; married; family his-
tory negative. Patient has always complained of pain in her abdo-
men and more or less vaginal discharge. Had diphtheria at nine-
teen, and has suffered much from sore throat at various times since.
In 1S93 had typhoid pneumonia. For the past three years has been
in bed much of the time. Has always worked as much as her strength
would permit. No unusual exposure. Bowels always constipated, and
has had much bladder trouble for three or four years ; sometimes could
not retain urine, at other times had to be catheterized. Two years ago
had a severe bronchial cough which lasted for some time, and has had
more or less rheumatic trouble since. After her attack of diphtheria
she noticed a bearing-down pain; menstruation irregular ; at times a
leucorrhcea was noticed, and patient has grown gradually worse. Pain
felt in hips, back, and chest. Has had a number of chills at irregular
intervals. For past two years has not been able to do much work, and
in bed the greater part of the time. Appetite fair ; no nausea nor vom-
iting; bladder trouble at the present time (June, 1900), very much
better. Has lost in weight nearly fifty pounds, and -is much weaker
than she was a year ago; greatly constipated. Has noticed some
enlargement of abdomen, and on being examined by her family phy-
sician, Dr. A. J. Blessing, was told she had some tumor in connection
with the uterus, probably fibroid in character.
I saw her on June 13, 1900, confirmed the diagnosis made by her
family physician, and advised an operation, because of the fixed posi-
tion of the fibroid in the pelvis, which I believed was also causing
some pressure upon the vessels, and producing much of her trouble.
Examination of urine normal. Abdomen presented a rounded, sym-
metrical appearance; slight tenderness in lower portion ;> reflexes
normal.
On June 15, 1900, I did a median incision, and exposed the fibroid,
which filled the pelvis snugly. By means of the corkscrew it was
brought well up into the incision ; intestines kept back by means of
large gauze sponges ; broad ligaments clamped ; fibroid removed ;
amputation done just above the internal os. After controlling the
ovarian and uterine arteries, the peritoneal surface of the broad liga-
ment was brought together, and the stump closed with silk sutures, the
peritoneum over that. Incision in the abdomen closed by through-
and-through silkworm-gut sutures, and silver-foil dressing.
228 VANDER VEER,
This patient presented no unusual complication in her recovery
until the evening of June 30th, when her temperature reached 101.5°,
and she complained of much pain in her left leg. On examination it
was noticed that she had phlebitis of the femoral vein and of the in-
ternal saphenous and of the veins of the calf of the leg, the left leg
being much swollen. The case presented as one of distinct phlebitis
on that side. There was no marked tenderness on examination of the
pelvis. Bimanual examination did not reveal any phlegmon, and,
while there had been much obstinate constipation, the patient had
succeeded in getting a movement by the use of the triplex pills and
enemas. The leg was dressed with cotton and oil silk, and elevated ;
anodynes used to control pain ; cathartics were needed to keep her
bowels open. Patient was restless and despondent much of the time,
but eventually made a good recovery, and was discharged from the
hospital July 28th, able to walk about with the aid of crutches. She
returned to her home, and while suffering more or less neuralgic pain,
yet I am told by her family physician she has made a very satisfactory
recovery. This was a marked case, and her convalescence was greatly
delayed by reason of the attack.
Case IV. — Mr. W. H. B., aged twenty-nine years; married ; habits
good ; family history negative ; had diseases of childhood, but always
considered himself well with the exception of some decided constipation
at times; fairly hard worker; had seen severe exposure ; uses tobacco
moderately ; no alcohol, nor any history of specific trouble. Con-
sidered himself well until December, 1899; then one day noticed a
severe pain in the right iliac fossa, which gradually grew worse until
the fifth day, when he was ordered to bed by his physician. No vom-
iting. Patient remained in bed about a week, and then felt very well.
Had another attack two months later, and since then has had several
attacks; not necessary for him to be confined to his bed until this last
attack, about a month ago; was then in bed for two weeks, and suf-
fered severe pain, which was more localized, however; no nausea or
vomiting presented ; bowels regular ; had no chills or fever ; bladder
normal in its functions, and no cough : urine normal.
Physical Examination. Patient presented a strong, muscular ap-
pearance ; pulse strong, full and regular ; abdomen symmetrical and
flattened, if anything ; respiration normal ; slight tenderness over the
region of appendix. Diagnosis of his physician (Dr. Ball) confirmed —
i.e., recurrent catarrhal appendicitis.
Operation, June 21, 1900. The appendix was found very long.
i
PHLEBITIS FOLLOWING ABDOMINAL OPERATIONS. 229
measuring nearly seven inches and containing several concretions of
fecal matter in distal extremity ; some few adhesions, but not severe.
The stump was invaginated with fine silk — in fact, usual operation
done, and usual method of closing incision by layer sutures; no drain-
age. This patient progressed very favorably, and had no untoward
symptoms. Slight rise of temperature on third day. On the 26th the
evening temperature was 102°, and patient complained of decided pain
in the left leg. Marked pain on pressure over the femoral vessels and
the calf of the leg. On the 28th the temperature reached 103!°, ^^'
went down the morning of the 29th to gg^° ; then up to 103°, and re-
mained there until the morning of July ist, when it dropped to 99^°.
The patient's limb was wrapped in cotton and oil silk, carbonate
of ammonia given internally, bowels thoroughly emptied, and from
this time on there was no rise of temperature, nor did his pulse
go above 98. He made a good recovery, and left the hospital July
10, 1900. The swelling gradually disappeared, and when I saw him
a month later there was no tenderness nor thickening of the vessels to
be made out. This patient had no unpleasant symptoms on pressure
over the region of the appendix after the operation, nor did he give
evidence of pelvic com.plications.
The literature on the subject of venous thrombosis and of
phlebitis following abdominal operations is not very extensive.
The contributions of such men as Lennander, of Upsala ;
Strauch, of Moscow ; VVyder, Mahler, Lee, McKenzie, Fox,
and more recently of Welch, Coe, and Willy Meyer, give about
all that is to be obtained bearing upon the subject, and yet it is
not absolutely clear to either of these authors that the cause is
of septic origin.
Welch is particularly impressive in this direction, and we cer-
tainly have much more to gather in and study carefully before
we can be quite sure as to the causes of this lesion. In none of
my cases could be found a condition of auto-infection, for I am
particularly thorough in having the bowels emptied before an
operation and to attend to it somewhat promptly afterward.
In looking over the histories of these cases there does not pre-
sent any evidence of complications in this direction. I am not
altogether clear but that the tight bandage may have had some-
thing to do with two of my cases. The bandage I now employ
230 VANDER VEER,
is the Scultetus, and it is sometimes possible to bring the lower
band a little tighter than others, something I am now convinced
my nurses should be warned against. In neither of these cases
was there delay in union of the wounds. All went well, and
healing was primary and thoroughly aseptic. There was no pro-
longed vomiting from anaesthesia, and in neither case was there
the evidence of phlegmon, either in the pelvis or otherwise.
It will be noted that pain was one of the pronounced symp-
toms, and in two cases out of proportion to the apparent lesion,
butthe vessels did present the characteristic cord-like sensation,
and within a very short time after the pain indicated the lesion
that was present.
The feel and sensation of distress and increased pain was an
early symptom. It will be noted that the temperature and pulse
were markedly accelerated when the ushering in of the lesion
presented.
These cases indicate that neither sex escapes, nor can it be
said that the operations were all of the same nature. One was
an operation for appendicitis ; another a case of uterine fibroid
of long standing. In this latter case it is to be noted that the
patient had suffered from phlebitis in early life, and had pre-
sented all of the objective symptoms of varicose veins.
One was a case of double ovarian tumor, another a rare form
of tumor of the liver, so that the four cases present quite a
variety of lesions. The position of the patient during the time
of the operation I have studied carefully, and am able to say
there was no change from the horizontal position, with no
pressure upon any particular part of the lower extremities ; no
elevation of the pelvis or changed position especially. Loss of
blood but slight in either case. Condition of patient, so far as
being an?emic or feeble or weak, was indicated to the contrary,
with the exception of the case suffering from tumor of the liver,
where there was a marked anaemia present, and he did not take
ether especiall}'' well. At one time he was quite cyanosed, and
required artificial respiration for a short period.
The kind of ligature used was the same I have employed in all
of my abdominal operations, the finest silk sufficiently strong for
i
PHLEBITIS FOLLOWING ABDOMINAL OPERATIONS. 23I
the purpose ; no catgut used within the peritoneal cavity. While
I have all confidence in the latter, still my early experience as a
general surgeon has made silk a favorite ligature, and with the
sterilization we are able to give it I have no reason to make a
change in this direction.
It has occurred to me that the anatomical distribution of the
veins on the left side, as in varicocele, may have a bearing upon
the pathology of these cases. Constipation certainly must be
considered, and, as in all work within the abdomen, should be
overcome or relieved before operating.
That the cases have made a good recovery is a source of com-
fort and consolation, but that they give additional care during
convalescence cannot be denied, and one feels that if we can reach
the etiology and pathology of such a condition it would be very
desirable, eliminating even this factor of worry in this class of
surgery.
Ether was used as the anaesthetic in all these cases ; urine care-
fully examined and found to be normal.
Concerning venous thrombosis of the lower extremities after
coeliotomy in the high pelvis position, and ether narcosis, Dr.
Strauch remarks : " After attending the Fifth Gynecological
Congress in Breslau, in May, 1893, after visiting Vienna and
attending the Schautaschen clinic, and seeing ether narcosis for
the first time, and having had some unpleasant experience in
asphyxiation from chloroform, I determined to try ether in my
private clinic." On June i, 1893, he performed his first cosli-
otomy under ether narcosis, in the high pelvis position, and up
to January, 1894, had done nineteen cceliotomies : Seven ovari-
otomies ; five myomectomies ; three appendage operations ; two
ventral fixations ; two extra-uterine pregnancies. And of these
cases he observes that three suffered from venous thrombosis of
the left lower extremity. He describes these cases somewhat
fully as follows :
Case I. — Ansemic patient, aged forty-six years ; strong heart-beat.
Had been curetted three times on account of hemorrhage from a
myoma; success only moderate. On June i, 1893, supravaginal
amputation of uterus on accouat of a fast-growing myoma in the
232 VANDER VEER,
anterior uterine wall. Bleeding from appendages severe. Intraperi-
toneal treatment of stump. Operation one and one-half hours. Ether,
360 grammes. Normal convalescence to seventh day. June 9th, pain
in left parametrium ; left lower extremity much swollen ; subcutaneous
veins visible. Combined examination revealed pelvis in safe condi-
tion. Under high elevation, cotton and oil-silk bandages, oedema and
hardness of veins disappeared in three weeks. Leg bandaged when
patient left bed on thirty-first day, and continued swollen.
Case II. — June 10, 1S93, i^emoved an ovarian cyst, size of a man's
head. Patient, aged twenty-eight years, powerfully built, neurasthenic
woman. Cyst circumscribed ; adhesions on right side ; cyst twisted on
its pedicle 360°. Tied in three places; silk sutures; operation lasted
twelve minutes. Uneventful recovery ; stitches removed on tenth day,
and primary union.
On fourteenth day there arose a typical venous thrombosis of left
lower leg. Patient remained two weeks longer in bed, and the last
time seen she complained of pain and slight swelling of the leg.
Case III. — Ovariotomy, January 20, 1894. Patient, powerfully-built
woman, aged thirty-two years ; the end of third month of her first preg-
nancy. There was a non-adherent, immense tumor springing from the
left ovary, and coming from a small, irregular cyst, with very strong
adhesions. Tumor had developed so rapidly before patient was seen
that the incision, of necessity, was lengthened over the navel. The
stump was eleven millimetres wide, with a twisted pedicle, the latter tied
off in three parts, and sutured with silk, as far as possible, toward the
tumor.
After removal of the tumor the patient was put back in the horizon-
tal position. Was five, possibly eight minutes in high pelvis position,
but legs were held by a very intelligent midwife, and knees bent high-
est on right side. Ether used, 240 grammes. There were uterine con-
tractions on the day after the operation, and patient was given tincture
of thebane. On the third day there was slight osdema about left mal-
leolus, which quickly disappeared. One hundred hours after opera-
tion the patient awakened with a loud cry ; shortness of breath, cold
perspiration ; small, ragged pulse, and strained, anxious countenance.
No doubt was left regarding the diagnosis — embolus of the lung had
occurred. Under treatment the patient recovered again on the third
day ; but lower extremity, on the fourteenth day after the operation,
still looked somewhat as in the beginning. One could see the sub-
PHLEBITIS FOLLOWING ABDOMINAL OPERATIONS. 233
saphenous veins show through. Abdominal wound healed kindly, and
pregnancy continued to term.
Dr. Strauch asks : " How, then, is this highly fatal complica-
tion to be explained ?" From personal observation with the
high pelvis position, and from several operators in Austria and
Germany, I am convinced that no fault is to be attributed to
my table. The Rosshair table protects the knees nicely from
pressure, but this position does give a somewhat hindered cir-
culation of the lower limbs. Chloroform brought no disaster
from this position. Under chloroform I was always accustomed
to guide my prognosis by the appearance of the pulse curve
the first three days after the operation, but it is not possible
under ether. Under the nineteen cceliotomies twelve cases are
recorded where the pulse the first three days went up to 120.
In none of these cases was there great loss of blood. It ap-
pears, therefore, the specific working of the ether, plus the high
pelvis position, has brought about this unpleasant complication.
It is somewhat remarkable that this always happens in the
left lower extremity, and one cannot help but be impressed
with the idea that the left leg is more strongly bent during the
operation, because held in the right hand of the assistant. I am
not at all certain whether to blame the ether or the position,
but, in order to obviate the leg resting upon the sharp edge of
the table, I do not allow it to be held by an assistant, but
fastened up with straps.
It will be observed that this report was made in 1894, and
yet how few cases or papers on the subject have been presented
to the profession since.
Treatment certainly consists in rest, elevation of the limb,
free movement of the bowels, anodynes to control pain, later
hypnotics to afford sleep, and diffusible stimulants and tonics
as may be required.
Bibliography.
Lennander. Centralblatt (iir Chirurgie, May 13, 1899.
Coe. Medical News, July i, 1899.
Strauch. Centralblatt iiir Gynakologie, 1894, p. 304.
^ Meyer. Annals of Surgery, May, 1901.
Welch. AUbutt's System of Medicine, Thrombosis and Embolism, p. 195.
234 DISCUSSION,
DISCUSSION.
Dr. George Fowler, of New York.
The importance of this lesion complicating abdominal operations
deals of course with the frequency of its occurrence, with its mortal-
ity, and with the disability following its occurrence. In reviewing
the work during the past fifteen years in abdominal operations, I find
that there were upward of 3000 cases in the hospitals with which I am
connected, and that, deducting those cases in which opportunity was
not afforded for the development of phlebitis (for it is a development
of some days, and frequently weeks, following operation), there were
271 1 cases. Of these 16 developed phlebitis, or 0.59 per cent. Of
these two were double, or two-sided, to followed cases of appendicitis
in which decided infection was present. The remaining 6 occurred in
operations upon the pelvic organs not necessarily involving a pre-
existing or followed by a post-operative septic condition. Basing my
remarks upon the 16 cases I should state that the disease has never
occurred earlier than ten days following an operation, nor later than
twenty-eight days. When it follows operation it usually develops
in from ten to eighteen days, and is insidious in its onset. There are
practically no symptoms save an increased acceleration of the pulse
without a rise of temperature, or with practically none, until the
patient complains of stiffness and soreness about the lower extremi-
ties, with some pain along the line of the vessels. Oa investigation it
was found that more or less induration could be felt along this line,
and a peculiar rope-like feel could be distinguished which apparently
extended above Poupart's ligament, the tenderness being traced
upward above this point. Therefore, the diagnosis would be based
(i) upon the increased pulse rate without a corresponding rise of
temperature, there seeming to be some circulatory disturbance which
increased the pulse rate without affecting the temperature; (2) the
feeling of indefinite distress in the extremity ; (3) the induration along
the lines of the vessel extending above Poupart's ligament. The prog-
nosis in these 16 cases has been good so far as other complications are
concerned and loss of life, as they all recovered. None of the large
number of reported complications of such cases, such as thrombosis
and pulmonary infarction, occurred in these cases. However, there is
this much to be said : there is more or less disability and disturbance
PHLEBITIS FOLLOWING ABDOMINAL OPERATIONS. 235
of function. This may amount to an inability to use the limb well,
or sometimes necessitates the use of crutches for the first three months
after operation. In one case more or less disability existed for a
year, the patient being compelled to wear elastic bandages.
Dr. W. J. Mavo, of Rochester, Minn.
I was very much interested in this paper and also in Dr. Fowler's
remarks. For about two years I have had this matter under observa-
tion, and I have made some investigations in the cases I have had. In
that time we have met something over 12 cases, which has been about
I per cent, of the number of abdominal cases in the hospital, and there
were some queer things brought out by this study. The most impor-
tant point that I wish to make is in connection with the question of
pulmonary embolus. Three cases of pulmonary embolus occurred
during this time, one dying and two recovering, though they were in a
very dangerous condition. In the two cases that recovered the acci-
dent happened before the time of phlebitis, and both of them were
followed by phlebitis. One came on the fifth and the other on the
tenth day, the embolus, as I have said, preceding the phlebitis. The
case of embolus that died had a firm and steady pulse up to the time
of death, showing that the heart had continually forced the blood
into the lung. In the two that recovered the heart was exceedingly
weak, undergoing rapid dilatation, and it was this weakness that en-
abled them to tide over. The strength of the heart in the case that
died practically prevented recovery. I do not think that phlebitis is
necessarily confined to pelvic cases, as I had one following a simple
gall-bladder operation, and we see many following simple appen-
dectomies.
I am not able to state why the condition is more frequent on the
left side than on the right, but it seems to be so, although we had
three cases in which the right limb was involved, and two in which
both limbs were affected.
Dr. Turner, of Baltimore.
I would like to ask Dr. Vander Veer if the condition of phlebitis
has been noted in operations for hemorrhoids.
Dr. Vander Veer. Replying to the remarks of Dr. Turner, I would
state that the tumor in my case was not quite as large as my fist, and
rested closely upon the vena cava, but no hemorrhoids were present.
236 PHLEBITIS FOLLOWING ABDOMINAL OPERATIONS.
I was very much interested in the remarks of Dr. Fowler and Dr.
Mayo. A year ago last March my assistant looked up the number of
celiotomies that had been done in the Albany Hospital, and found
that my own numbered about 1500. Aside from the case to which I
referred that died, none others had attracted our attention as to
venous thrombosis ; therefore, the cases two years ago rather startled us.
The rarity of the lesion and the want of instructive pathology were
the two points that I especially wanted to bring out to day.
Dr. Frederick Lange, of New York.
As to the prognosis of those cases in which phlebitis of the lower
extremity becomes apparent, my experience coincides essentially with
what has been said, but I have to report two cases of death from pul-
monary embolus after extirpation of large fibroids. They were cases
in which there was every reason to assume that they would take a
normal course to recovery ; but each one, at the end of the first week,
succumbed in a few hours to the characteristic heart symptoms of
embolism.
The formation of thrombi in such cases is certainly favored by the
slow blood-current in the much dilated and ligated veins, and needs
not to be caused by infection. On the contrary, I am inclined to
assume that a certain degree of inflammation may give some protec-
tion against embolism by greater adhesion of the thrombus to the
wall of the vessel. My fatal cases had not presented any symptoms
of inflammation. On the other hand, I do not remember a case of
death among those cases in which, with progressing thrombosis, one
could speak of a phlebitis of the lower extremities.
TRAUMATIC ARTERIO-VENOUS ANEURISMS OF
THE SUBCLAVIAN VESSELS, WITH AN ANA-
LYTICAL STUDY OF FIFTEEN' REPORTED
CASES, INCLUDING ONE OPERATED.
By RUDOLPH MATAS. M.D.,
NEW ORLEANS, LA.
Synopsis : A case of traumatic {gufishot) arterio venous aneutis?n of
the right subclavian vessels, involving the artery within the scaleni ;
division of the atiery between ligatures placed on the first and third
divisions ; detachment of the anastomotic confiection ; lateral suture of
the venous orifice ; osteoplastic resection of the clavicle under eucain B.
ancesthesia ; recovery, with partial loss of hand aftd forearm from
arterial ischcemia. On September 8th, Moise Miller, a young Arcadian
habitant (farmer), native of Rayne, Arcadia Parish, La., was brought
to me for treatment at the New Orleans Sanitarium. His attending
physician, Dr. C. H. Power, of Rayne, who kindly referred him to
me and accompanied him to the sanitarium, gave the following par-
ticulars of his history and of the circumstances under which the injury
was inflicted. We may premise the history of the injury by stating
that he is a robust and exceptionally healthy man, aged twenty-four
years, married. He is broad-chested, muscular, frugal, and temperate ;
very calm, collected, and courageous. In health he weighs 165 to 170
pounds, and is six feet in height. He is very industrious and active,
' While this article is in press two additional observations of arterio-venous aneurisms
involving the subclavian vessels have been reported by MM. Gallois and Piollet, of
Lyons, in a contribution on vascular injuries caused by simple fractures of the clavicle.
(" Les dechirures vasculaires par fractures fermees de la clavicule," etc., in Revue de
Chirurgie, Paris, No. 7, 21 annee, July 10, 1901.) These observations, together with the
case of Vasilyeff (ulceration of both vessels in abscess cavity), have reached me too late
to be incorporated in the text, but will be found in the final table of the reported cases,
which epitomizes the history of seventeen cases of arterio-venous aneurisms of the sub-
clavian vessels, instead of the original fifteen tabulated up to the date of the meeting.
238 MAT AS,
and has always been engaged in out- door pursuits. His past history
and that of his parents, who are living, reveals no antecedents which
bear upon his present troubles.
On Monday, September 3, 1900, six days before his arrival at the
sanitarium, and while attending a country festival near his home in
Rayne, he became engaged in a personal difficulty at about 8 p m.
In the struggle that followed he succeeded in throwing his antagonist
to the ground, and while holding him down with both hands the lat-
ter drew a revolver from his pocket, and, raising it, pressed the muzzle
close to Miller's chest and fired.
Immediately after the shot he (Miller) felt the grip of his right hand
relax and realized that his arm had been paralyzed. The spectators
in the meantime parted the combatants, and Miller was at once driven
in a buggy to Dr. Power's residence, a distance of one mile. Though
very weak, the patient stepped out of the buggy without assistance
and walked a few steps into Dr. Power's office, when the latter saw
him, about forty minutes after the shooting. After a hasty examina-
tion, sufficient to convince the doctor that the injury was of a very
serious character, he applied a compress of iodoform gauze over the
wound and secured this in place with adhesive plaster. The blood
had soaked through the patient's clothing and was still flowing out of
the orifice of penetration when Dr. Power applied the compress. The
bullet wound was small, however, and this moderate pressure succeeded
in arresting the bleeding, though it was evident by the rising swelling
in the neck that a concealed hemorrhage was now progressing actively
in the neck. After a few minutes' delay the patient was helped to his
buggy and conveyed to his home, a distance of one mile, where he
was at once put to bed and an ice-bag applied over the injured area.
At no time did the patient lose consciousness, and it was not until
he had reached his home that he showed signs of great prostration and
shock, which became intensified as the night advanced and the swell-
ing in the neck and shoulder increased.
At the examination, made early that night at the patient's home,
Dr. Power, in consultation with Dr. Webb, ascertained the following
facts : The patient had been wounded by a revolver bullet (Smith &
Wesson, 38 calibre), which had penetrated in the right second intercostal
space about three inches from the right margin of the sternum. The
bullet had ranged obliquely upward and backward, inclining slightly
toward the right, evidently passing under the clavicle without fractur-
ing the bone, and finally lodging under the skin at a point corre-
i
TRAUMATIC ARTERIO -VENOUS ANEURISMS. 239
spending to the anterior border of the trapezius, midway between the
mastoid and the acromion, where it could be felt distinctly by the touch.
A large swelling had formed in the neck immediately after the injury.
This was caused by a large hsematoma, which extended from the
shoulder to the angle of the jaw laterally and from the second rib
to the scapular region anteroposteriorly. All external bleeding had
stopped and only a bloody ooze stained the dressings. The skin for
some distance around the bullet wound was powder stained and burnt.
The most notable sign that attracted the attention of the attending
physician at this time (not more than two hours after the injury) was
the "intense throbbing or pulsation which was perceptible in the
swelling on the chest and neck, and a loud thrill, which could be felt
along the course of the subclavian vessels, extending over the neck up
to the angle of the jaw and down the shoulder and upper arm." The
pulse in the arteries of the right arm was absent. It was also noticed
that the arm on the opposite side was motionless and anaesthetic all
over th^ hand and forearm. Evidently there had been a coincident
lesion of the brachial plexus.
The general condition of the patient had grown worse since his
return home. Coincidently with the development of the swelling
and aneurismal signs, he had become weaker ; he now showed positive
signs of shock and profound exhaustion ; he was cadaverically pale
and the skin was covered with a profuse perspiration. The pulse on
the sound side was rapid and small. He had lost a considerable quan-
tity of blood (sufficient to soak through his clothing) immediately
after his injury, but this had ceased readily under slight pressure with
the gauze pad applied by Dr. Power. It was evident, therefore, that
this condition of progressive shock was due to the concealed bleeding
in the hsematoma. A compress was reapplied over the wound, and
this again was covered with the ice-bag. By midnight (four hours
after the affray) the patient was so completely collapsed that he was
believed to be moribund, and no hope was entertained of his recovery.
He remained in this apparently dying condition until noon of the
following day (September 4th), sixteen hours after the injury, when
the first signs of improvement were noticed and the patient began to
rally. With this improvement the enormous swelling in the neck began
to harden and contract, though the pulsation and thrill remained un-
changed.
Dr. Power then states that the patient's temperature was above nor-
mal and fluctuated daily (September 4th to 8th) from 100° in the morn-
240 M A T A S ,
ing to 103° in the evening. By absolute rest, diet, careful stimulation,
and watchful nursing the patient continued to gain strength, though
slowly. It was noticed, however, that the throbbing and thrill in
the supraclavicular swelling continued to grow more diffuse and in-
tense as the swelling diminished. No notable improvement was ob-
served in the condition of the arm, which continued to be " of no use
to the patient" and remained pulseless at the wrist and in the arm.
This was Miller's condition when he was brought to the sanitarium
in New Orleans on September 8, 1900.
When I called to see him he was lying in bed, still extremely pale
and exhausted from his long journey and the exertion involved in
transportation from the train to the institution. His expression was
anxious, and there was some complaint of pain in the neck. The right
pulse, which had disappeared completely, was felt at the wrist very
faintly to-day for the first time (fifth day after injury), showing some
re-establishment of the collateral circulation. At 11.30 a.m., when the
patient was admitted, his temperature was 98.8°, but in the evening it
rose to 101°, with a pulse of no and respiration 22.
Upon examining the patient I first observed a dark circular slough,
the size of a silver quarter, in the skin over the right second inter-
costal space, about three inches from the sternum. Numerous inflamed
powder stains sprinkled the skin, testifying to the close proximity of
the pistol when fired. The entire supraclavicular region is swollen, also
the region of the trapezius, entirely obliterating the normal outlines
of the clavicle; in the neck a space as large as the palm of the hand
is bluish-black from extensive ecchymosis. The centre of this spot is
particularly dark and corresponds to the site of the bullet, which can
be felt distinctly movable in a bed of semi-fluid haematoma. The skin
of the entire supraclavicular region from the angle of the jaw to the
shoulder on the right side is discolored from the deep subcutaneous
extravasation. There is a very distinct subcutaneous heaving pulsation,
this being most marked along the course of the subclavian vessels and
the right internal jugular vein. This vessel swells and fills up the
suprasternal space with each beat of the heart. The superficial veins
of the neck and arm, the cephalic and basilic veins down to the elbow
are all unusually prominent, and their dark-bluish color stands in
conspicuous relief against the unusually pale, waxy skin. On palpa-
tion there is marked pitting on pressure from oedema, over the clavicle
and the entire supraclavicular region ; the general pulsation seen over
the supraclavicular region is distinctly confirmed by palpation. A
Arterio-venous Aneurisms of the Subclavian Vessels. Case of M. M.
Photograph taken seven months after operation, showing scar of incision in neck after
resection of clavicle, etc., and condition of arm and hand after healing. (Scar-lines have
been purposely intensified in plate to show lines of incision more plainly.)
TRAUMATIC A RT E R I O-V E N O US ANEURISMS. 24I
widely diffused and intense purring thrill can be felt by the most
superficial contact with the surface all over the neck, and more espe-
cially over the subclavian, jugular, cephalic, and basilic veins. The
thrill appears to be transmitted in all directions from its point of
greatest intensity, immediately above the middle third of the clavicle,
all along the venous currents of the neck and arm as low down as the
right hand. The most striking phenomenon is the peculiarly loud
murmur which is heard all over the neck, chest, and arm, along the
course of the venous trunks. This murmur is difficult to describe ; it
is a continuous hum, with diastolic whirring accentuations, and is
heard with greatest intensity over the middle of the clavicle, and is
harsh, buzzing, and, in fact, indescribable. Several odd comparisons
were made by those who heard it, but no description or analogy ap-
pears to give an accurate idea of its extraordinary peculiarities. This
murmur is so loud that it can be heard by listening attentively at a
distance of nearly one inch from the surface.
This murmur, like the thrill, is propagated with greatest intensity
along all the venous trunks from the bend of the elbow to the innomi-
nate veins and superior vena cava. It can be heard distinctly over
the facial and temporal veins. Its vortex or loudest point is over an
area the size of a silver dollar, situated just above the middle third of
the clavicle, in the very centre of the bullet tract, and evidently in a
line with the subclavian vessels.
In spite of all this tremendous vascular upheaval and disturbance,
the work of repair was evidently progressing steadily in a favorable
direction. The swelling of the original area had on the ninth day
markedly subsided ; the extravasation was being absorbed, and it was
evident that the large stream of blood which was being poured out of
the artery had found a direct outlet in the veins; these had accom-
modated themselves to the abnormal pressure, and were carrying off
the overflow through comparatively safe channels back again into the
circulation. Associated with these evidences of vascular disturbance
there still remained a marked paresis of the entire right arm down to
the fingers. The arm could be moved slightly by strong voluntary
efforts, but pronation and supination were impossible, the arm usually
remaining motionless, extended and passive by the side of the body,
or it remained inert in which ever position it happened to be placed
by the patient's left arm or by the hands of the attendants.
The sensibility was impaired all over the arm up to the shoulder,
but sensation could be elicited by deep pricking with pins over the
242 MATAS,
fingers and hand on the palmar and dorsal surfaces. The thermic
sense was also greatly impaired, but the application of very hot water
to the hand, as in washing this part, elicited some sensation on the
part of the patient. The condition was really one of parsesthesia and
paresis rather than paralysis, and this encouraged the belief that the
injury to the brachial plexus was a contusion and partial laceration
rather than an actual division of its constituent trunks.
Diagnosis. By summarizing the evidence thus clearly presented the
following points were determined : i. That the course and direction
taken by the bullet indicated that the missile had penetrated the neck
by passing under the clavicle without injuring it, had crossed the path
of the subclavian vessels just about where the scalenus anticus crosses
the artery, and after injuring both artery and vein had grazed and
contused the brachial plexus.
2. The immediate cessation of the radial pulse at the time of the
injury, which continued to be imperceptible until the fifth day, and
the coldness of the skin and pallid appearance of the arm, indicated
that the circulation in the subclavian had been interrupted by the
injury.
3. The positive and pathognomonic signs of arterio-venous aneurism
or varix, i. e., the continuous venous hum plus the rasping, buzzing
double murmur heard with greatest intensity in the diastolic period
(Broca and Wahl's signs), the intense vibratory purring thrill {fre-
missement caiaire), propagated like a murmur at a great distance along
the venous channels on the proximal and distal sides of the point of
injury.
4. The spontaneous arrest of the bleeding shortly after the first
primary hemorrhage, the absence of secondary bleeding, and, above
all, the rapid subsidence of the haematoma while the intensity of the
physical signs of aneurism were increasing ; the great fulness, pulsa-
tion, and distention of the cervical and brachial veins, more espe-
cially during the diastolic period — all clearly pointed, in fact, demon-
strated, that the subclavian artery and vein had been simultaneously
injured by the bullet, the perforation leading to the almost immediate
formation of an arterio-venous anastomosis.
It also appeared to be most probable that the anastomosis was a
direct one (aneurismal varix) and not through an intermediary sac
(varicose aneurism), though this point could not be positively de-
termined at the time in consequence of the swelling above and under
the clavicle in the neighborhood of the bullet tract. There was, how-
TRAUMATIC A RTE R I O- VEN O US ANEURISMS. 243
ever, no distinct globular or especially defined swelling. There was
only a general hard swelling over the supraclavicular space filling the
lateral aspect of the neck as with a mass of recent exudates and extra-
vasated products, all masked by a dense, doughy oedema of the skin.
At first the entire supraclavicular region appeared to expand and pul-
sate as a whole, all over, with each beat of the heart ; but latterly, as
the swelling diminished, the pulsation was more defined and distributed
most intensely along the veins embedded in the mass of exudates.
Having sufficiently disposed of the question of diagnosis, we were
now ready to consider the more serious problem of treatment. What
were the indications furnished by this remarkable and rare lesion? If
we bear in mind the fact that the patient had come to us for treat-
ment on the fifth day after injury, and was still suffering from the
shock and anaemia incident to the primary injury, and that the eschar
existed, we will realize that we had reason to consider the possible
dangers that menaced this patient from two points of view: First, the
possibility of secondary hemorrhage ; second, the remote dangers in-
cident to the formation of a secondary or consecutive aneurism of the
artery proper, with all its attendant train of evils and dangers. As to
the immediate dangers of possible infection and secondary hemor-
rhage, we were soon able to satisfy ourselves that they, at least, could
be safely eliminated by a careful observation of the patient's con-
dition during the first four days that followed his admission to the
sanitarium.
From the moment that the patient was admitted to the institution
the injured surface was subjected to the most careful antiseptic treat-
ment and methodical compression with bandages and ice-bags. The
whole region was carefully washed with potash soap and lysol solution
(i per cent.), followed by alcohol. Wet antiseptic compresses were
applied, and the whole supraclavicular region and lateral surfaces of
the neck were subjected to vigorous compression with a spica bandage,
over which an elastic woven bandage was adjusted, and over this a
large ice-bag was applied. This firm elastic compression, with the
addition of cold, promoted the absorption of exudates and extrava-
sated products, and we hoped also that it would help to moderate the
violence of the strain that was being constantly forced upon the veins
through the aneurismal orifice. With these simple measures, aided
by absolute rest, a light nutritious dietary, consisting chiefly of milk,
fruit, broths, and cereals, and other hygienic measures, the robust na-
ture of the patient soon asserted itself. The temperature, which upon
244 MATAS,
admission had oscillated between ioi° and 102° F,, gradually sub-
sided, so that by the fourth day (ninth after injury) it rose no higher
than 99°. The pulse likewise moderated in frequency, and fell
to 84-90. The discoloration of the surface rapidly diminished, the
dark bluish-black area of extravasation being limited to the spot occu-
pied by the bullet. The eschar at the wound of entrance fell off
September nth (eighth day after injury), leaving behind a healthy,
granulating surface. The pain and superficial tenderness over the neck
and chest diminished daily; the cedema, which had completely ob-
literated the clavicle and all the surface anatomy of the region, now
subsided, and the clavicle was easily outlined under the thin skin. It
was evident from all these signs of improvement that the danger of
infection which we had first apprehended from the fever, the pain and
the tenderness over the parts, could now be definitely eliminated.
And as there was no oozing at the point of entrance or other warnings
of secondary bleeding, I now felt encouraged to believe that this grave
source of apprehension would also soon be eliminated. On the other
hand, the physical signs of the aneurism became, if anything, more
pronounced as the cedema of the skin subsided. The hum, murmur,
and thrill became more noisy and turbulent, and could be studied to
still greater advantage as the vessels approached the surface. The
swelling and turgidity of the jugular and brachial veins also became
more perceptible. The pulsation in the internal jugular was most
striking. With every beat of the heart this vessel pulsated so forcibly
and became so distended that it filled the entire suprasternal and pre-
tracheal space, thus demonstrating that while the venous system had
accommodated itself to the new conditions, and was standing the
great strain imposed upon it by the sudden shunting or short-cir-
cuiting of the arterial current, it was unavoidable to conclude that a
condition of permanent overdistention and engorgement was laying
the foundation for future evil. The paralysis of the arm still con-
tinued ; there was a slight improvement in the movements of the arm,
and the sensibility of the skin was more acute, but apart from this the
arm remained lifeless and inert by the patient's side.
For the moment all fear of immediate complications could be
dismissed, though we realized that fully three weeks after heal-
ing would have to elapse before we could safely state that the
danger of secondary hemorrhage could be entirely eliminated.
(See Will's case, secondary hemorrhage after healing of wound,
TRAUMATIC A RT E R I O-V EN O US ANEURISMS. 245
causing death three weeks after injury.) As the patient resided
in an isolated settlement in the country, and could not remain
long under our observation, the_ question that arose was,
" Should the patient be allowed to return home, with instruc-
tions to return again for further treatment in the event that
other serious developments should follow; or was it the wiser
plan to offer him the opportunity of anticipating the complica-
tions and dangers that the future might have in store for him,
by proceeding to an early and radical attempt to rid him of this
dangerous lesion under the most favorable conditions of surgical
preparation ?
While the question involved many debatable propositions,
which will be more appropriately discussed in another section
of this contribution, I will state that in view of the progressive
improvement in the general condition of the patient, and the
probability that he would escape the dangei-s of secondary hem-
orrhage and other immediate complications, I had concluded,
in accordance with the classical recommendations on the subject,
that I would abstain from all operative intervention, and would
allow the patient to return home after the wound had healed
completely. Had I known the exact anatomical relations of
the aneurismal orifice, which were only determined at the time
of the operation, I would have made a special trial of systematic
digital compression over the anterior scalene after all the acute
reactionary swelling had subsided. But even with the favorable
position of the anastomotic orifice (immediately in the lowest
centre of the scalene tendon), it is very doubtful that this mode
of treatment would have succeeded, as the clavicle was directly
in the way of effective compression ; furthermore, in the cases
in which this method had been tried it had failed altogether,
and I therefore gave it little consideration. On the other hand,
the patient, who had been profoundly impressed with the gravity
of his injury, reminded me insistently that he would not be able
to remain in the city for observation, or to return again at some
future time if complications should arise, without a great sacri-
fice— a greater sacrifice than his limited resources would allow.
He was anxious to have something done that would be decisive
246 M A T A S ,
and that would relieve him permanently of the worry and un-
certainty of a lesion which he might tolerate in time, but would
always remain a menace to his comfort and even to his life.
The dangers of a radical operation and the unusual character
of such an operation were fully explained to him, but he pre-
ferred to take his chances, provided there was a reasonable
prospect of recovery and permanent cure.
The determined attitude of the patient, who showed himself
as fearless as he was determined, coupled with our serious mis-
givings as to the final outcome of the case if allowed to drift
along its natural course, led me, in spite of my grave doubts as
to the wisdom of this decision, to acquiesce to the patient's
courageous appeal and to give him the benefit of the operation.
Without underestimating the difficulties that were to be en-
countered, I still believed that by adopting a carefully prepared
and matured plan of action I would be able to overcome the
chief obstacles in the way of a safe dissection of the varix and
complete control of its anastomotic orifice. The main objects
of the operation that were kept in view were : (i) To obtain free
and easy access to the entire injured area by preliminary osteo-
plastic section of the clavicle from its outer third to the sterno-
clavicular joint, which was to be disarticulated or temporarily
excised. (2) To obtain complete provisional control of the sub-
clavian circulation by applying a temporary traction-loop upon
the first portion of the subclavian or innominate artery, which
by lifting the vessel from its bed would occlude the main trunk
and its most important collateral branch, the vertebral. (3) To
completely explore by careful dissection the point of anastomotic
communication existing between the subclavian artery and vein.
(4) To permanently control the subclavian artery over the distal
and proximal side of the anastomosis by ligature, and (5) to pro-
visionally clamp or ligate the vein above and below the venous
orifice as a preliminary to the extirpation of an intervening sac
that might exist between the vessels. Then (6), if possible, to
suture the venous orifice by lateral phleborrhaphy, thus allowing
the venous circuit of the upper extremity to be re-established
after the removal of the temporary clamps or ligatures on the
TRAUMATIC A RTE R I O-VENO US ANEURISMS. 247
vein. (7) To restore the parts to their normal condition by
wiring the divided clavicle into position. Incidentally, and as
a minor feature of the operation, the bullet would be extracted.
That this desirable but difficult programme would be carried
out in all its details I did not fully anticipate, but I did expect
to accomplish the main purpose of the operation if I once suc-
ceeded in obtaining a complete control of the innominate and
obtain a free and open field for the manipulations necessary to
dissect the anastomosis. As the sequel and details of the oper-
ation show, unexpected anomalies in the arterial distribution
and the freedom of the collateral supply did come near upset-
ting my plans and added greatly to the perils of the patient.
Nevertheless, the value of a carefully planned operation and
thorough preparation for emergencies was certainly well illus-
trated in this case, and while it may remain a debatable ques-
tion whether a procedure of this kind is justifiable in just such
conditions as those described in this case, it cannot be denied
that the final result obtained, even at the price of a mutilation of
the paralyzed hand and arm, is far more satisfactory (consider-
ing the specially unfavorable conditions under which this patient
was placed) than the uncertainty of leaving this grave lesion
without interference to the care of nature alone.
Operation. On Thursday, September 13, igoo (ninth day after
the injury), after all preparations had been completed, and with the
valuable assistance of Drs. H. B. Gessner, S. M. D. Clark, John Smyth,
U. Maes, and Dr. Power, who acted as recorder, the operation was
undertaken. The operation was begun at 9.20 a.m., and it was 2.30
P.M. (nearly five hours) before the patient was taken back to his bed,
though the actual operative work did not consume three hours. ^
We will begin the narrative of the operation by stating that in an-
1 Much of the time was consumed in giving the patient periods of rest, especially
during the local anassthesia stage of the operation. During these rest periods, as is
often done in tedious operations under local anaesthesia, the patient was given freely of
ice water, panopepton, toddy, and even beef tea, all of which he enjoyed immensely, and
which helped him greatly to control himself. Even after chloroform had been adminis-
tered he was never fully unconscious, except for a few moments, and would frequently
rouse up to call for ice water or other drinks, which were given to him liberally without
ever exciting nausea or vomiting.
248 MAT AS,
ticipation of the long duration of this operation and of the advantages
that would be gained by diminishing the risks of prolonged saturation
with a general anaesthetic, and with the view of diminishing the tur-
gescence of the jugular and other cervical veins, which were already
greatly distended, and would be likely to swell still more under gen-
eral narcosis and vomiting, I decided to attempt the preliminary
resection of the clavicle by means of local anaesthesia. I was encour-
aged in this by the calm and fearless temperament of the patient, who
showed no anxiety in the contemplation of the operation or of his
surroundings. It was not my intention to perform the entire opera-
tion under local infiltration anaesthesia, but simply to economize the
general anaesthetic by adopting infiltration anaesthesia during the first
stages of the operation, viz.: (i) the resection of the clavicle, and (2)
the application of a provisional loop around the innominate. The ad-
vantages of local anaesthesia during these two important stages of the
operation were not exaggerated, as we found subsequently, because we
were relieved of all anxiety and annoyance on the score of vomiting
or other disturbances in breathing from cyanosis, etc., which might
have caused a great turgescence of the jugular, subclavian, and innomi-
nate veins while exploring the pretracheal region for the innominate
artery. As it was, the patient gave us great assistance by voluntarily
changing the position of his head to suit our needs as we displaced
the distended and pulsating venous trunks of the aneurismal and cervi-
cal region. The stoicism of the patient under these circumstances,
his perfect immobility and passiveness, which permitted as deliberate
and free a dissection as on a cadaver, off"ered a truly remarkable spec-
tacle worthy of the greatest respect and admiration.
It was not until after the provisional security loop had been placed
upon the anomalous subclavian, and after a long and tedious search
had been made for the missing innominate, and not until we began
to encroach upon the deep branches of the cervical plexus, which
for obvious reasons we could not infiltrate, that he began to complain
of pain, and we at once proceeded to administer chloroform. This
was at 11.55, ^ little over two hours after the beginning of the opera-
tion ; the general anaesthetic was given in drop doses and interrupt-
edly from 11.56 to 1.30 (one hour and thirty-four minutes), after
which it was discontinued altogether. It should now be stated that
twenty minutes before beginning the operation the patient was given
i^ gr. morph. sulph. hypodermically, which is usual in my practice
as a routine procedure in all large local ann^sthesia operations.
TRAUMATIC A RTE R I O-V ENO US ANEURISMS. 249
In order to describe the operation systematically it will be divided
into the following stages :
First Stage. Section of the clavicle at the junction of the middle and
outer thirds. — For this purpose the skin overlying the clavicle and all
the periosteal tissue were densely infiltrated with Schleich's No. i so-
lution 1/5 of I percent., eight syringefuls, each containing 22 minims,
being used. The clavicle was denuded of its periosteum; two drill
holes were made on each side of the proposed line of section to facili-
tate wiring at a later stage, and the bone was divided with a Gigli
saw.
Second Stage. Formation of osteoplastic clavicular flap. — A curvi-
linear incision extending from the line of clavicular section two
inches below the clavicle, including the points of penetration of the
bullet, and carried across the right sternoclavicular articulation to
the middle of the neck, where it terminated opposite the lower border
of the thyroid cartilage.
This incision was made painless by a massive infiltration of 3)^ ozs.
of an isotonic saline solution of eucain B. (i/io of i per cent.) dis-
solved in 0.8 per cent, salt solution along the whole line of incision,
causing complete cedema of the infiltrated points. The whole surface
was covered with an ice and salt poultice, which was kept in place
eight minutes. The skin, subcutaneous tissues, and clavicle and sterno-
mastoid tendon, previously mobilized by section, were now elevated
and the sternoclavicular joints disarticulated, after previous peri- and
intra-articular infiltration of the tissues of joint with Schleich No. i
(1/5 of I per cent, of eucain B.). Some pain was experienced in mak-
ing traction upon the tissues of the neck while disarticulating.
Third Stage. Dissection and elevation of osteoplastic flap formed by
clavicle, skin, sternomastoid, and subcutaneous tissues. — The flap turned
up and rolled upon itself, exposing the deep cervical aponeurosis,
the sternohyoid and sternothyroid muscles, anterior jugular and thy-
roid veins, all large and pulsating ; termination of the cephalic into
subclavian lost in a mass of densely infiltrated tissues and exudates.
Time, 10.45 ^•^'- Pulse, 96, good; patient cheerful, but tired.
Very little bleeding thus far ; few ligations. In anticipation of more
exhausting work a hypodermic of i/ioo gr. digitalis and 1/30 gr.
strychnine were given, with a glass of ice water and 2 ozs. of strong
toddy. After an interval of ten minutes of rest, operation resumed.
Fourth Stage. Exposure and preparatory control of the vetious side
of the atieurism. — In view of possible hemorrhage from traction and
250 MATAS,
tearing the veins while elevating the osteo-cutaneous flap high enough
to clearly and freely expose the injured vessels in the region of the
scalenes, it was thought the better plan to begin this stage by thor-
oughly exposing the venous side of the aneurism. The subclavius
muscle, which had remained in the wound, on account of the close
enucleation of the clavicle, was now divided and excised. The
cephalic vein was exposed and followed to its terminus in the sub-
clavian vein, and the turgid bunch of veins formed by the posterior
scapular, suprascapular, transverse cervical, and external jugular veins
was dissected out with much difficulty on account of dense adhesions,
and traced to a common terminal in the subclavian. The subclavian
vein was now identified, but not without some delay, because it
seemed to be divided into two very distinct parts, one on the axil-
lary side being very much smaller than the other. This small axillary
part appeared to rise up in the neck, where it could be traced to an
ill-defined mass of organized exudates and extravasated products,
which completely masked the outlines of the scalenes. The brachial
plexus, the subclavian artery, and anterior scalene were all inextrica-
bly blended in the mass, which, judging by the pulsation and inten-
sity of the purr and thrill, must be the seat of the aneurismal orifice.
But the anatomical characteristics of the tissues were entirely lost ;
not even the tendon of the scalene could be made out, as it was
completely incorporated in the dense and resisting mass of exudates.
The axillary portion of the subclavian vein appeared to have been
dragged upward into this mass, forming an angle. (See diagram.) In
the proximal (cardiac) side the subclavian vein formed an enormously
distended trunk, which crossed over the first rib and was lost behind the
sternohyoid muscles, where it united with the internal jugular. The
contrast in the size of the axillary and cervical portions of the subcla-
vian was remarkable, and could only be accounted for by the formation
of a valvular projection in the bend of the vein, where it inosculated with
the artery. Catgut ligatures were now placed upon all the tributaries
of the subclavian as they entered into the axillary side of the vessel,
and a provisional silk ligature, not tightly drawn, was applied to the
main trunk itself, on the axillary side, a short distance before its
entrance into the mass covering the scalenes. The distended trunk
of the subclavian vein on the proximal side was now dissected care-
fully at a distance from the supposed point of anastomosis, in readiness
for provisional clamping or ligation when the arterial side of the
aneurism would be controlled. It was evident that any further ob-
TRAUMATIC A RT E R I O-V EN OUS ANEURISMS. 25I
stacle placed on the circulation on the venous side without previous
arrest of the arterial circulation would have led to such strain at the
anastomotic opening that it might have caused its premature rupture.
Fifth Stage. Exploration in search of the innominate and provisional
loop around anomalous subclavian applied. — The arterial trunks on
the proximal side of the aneurism were now explored with the finger.
Diagrammatic representation of arterio- venous communication (after excision of clavicle).
1. Scalenus anticus.
2. Scalenus medius.
3. Subclavian vein. The arrows show direction of arterio-venous current.
4. Internal jugular vein.
5. Innominate vein.
6. Axillary portion of the subclavian vein much reduced in size as a result of angular
traction from adhesion of vein to scalenus, and great distention of proximal side of vein
with arterial blood poured in by artery.
7. 7. Anomalous subclavian artery; the innominate absent (no carotid).
8. Anastomotic orifice indicated by dotted lines.
St. Sternum.
The subclavian artery could not be identified in the mass covering
the scalenes, and all efforts were centred upon securing control
of the vessel in its first division. The sternomastoid tendon at its
junction with the sternum, the sternohyoid and sternothyroid muscles
were freely divided at the junction with the sternum, and were re-
tracted with the overlying skin toward the left side of the neck by
252 MAT AS,
passing a loop of silk thread through the musculocutaneous flap thus
formed.
The first obstacle encountered was in the presence of the enlarged
internal jugular, subclavian, and innominate veins, which, upon being
freed from the confining restraint of the deep cervical aponeurosis
and tense muscles, immediately formed huge swollen trunks which
completely crowded the field of operation.
Fortunately, the disarticulation of the clavicle and free division of
the muscles of the anterior cervical region afforded a free and easy
access to the contents of the superior mediastinum. Taking the
internal jugular trunk as a guide, it was followed to its junction with
the subclavian and to the right innominate, which was clearly identi-
fied. By carefully displacing this to one side and the trachea on the
other, I expected to find the innominate artery without difficulty, but
much to my surprise I failed to find this vessel. Instead of this trunk
I found a very large vessel which ascended upward into the right side
of the neck in the direction of the subclavian artery ; but the com-
mon carotid was absent, and for the time being I was perplexed at
this unexpected state of affairs. In order to satisfy myself further, I
followed this anomalous vessel down into the mediastinum, and was
able to trace it with the tip of the finger to the arch of the aorta. I then
made a search for the common carotid in the upper part of the wound,
and was much surprised to discover that this trunk was absent from its
usual place, and evidently came from behind the trachea, and only
reached the surface at a high level near the thyroid gland. It was
evident, therefore, that there was no innominate artery, and that we
were dealing with one of those comparatively rare anomalies which
are familiar enough in the dissecting-room, but are extremely rare
in the history of surgical ligations. It took quite a while before I
could satisfy myself that the innominate was missing altogether, as I
had not anticipated this anomaly. Leaving anatomical explanations
for future consideration, I proceeded to place a provisional silk loop
for traction on the anomalous subclavian (Rivington's plan) on a level
with the sternoclavicular joint. When traction was made upon this
loop the pulsation and thrill in the subclavian area and in the veins
were arrested.
It evidently controlled the circulation in the aneurism at that
time. When this was ascertained, the loop was entrusted to Dr.
Gessner.
By this time (11.55 a.m.) the patient, who had been most patient
TRAUMATIC A RTE K I O -V EN O US ANEURISMS. 253
and calm, began to show signs of restlessness and physical exhaus-
tion, and I decided that the time had come to give him a general
anccsthetic. Chloroform was administered in drop doses, and pulse,
which had risen to 114, fell to 100 immediately after the first inhala-
tions. The patient was so tired physically and psychically from
prolonged mental tension that he inhaled the chloroform greedily. It
acted most happily upon him, and soothed him without producing
absolute unconsciousness, which he proved by replying intelligently
to our questions, making inquiries as to the progress of the operation.
He never complained of the least nausea, and drank repeatedly of
cold water, toddy, and even hot beef tea, whenever we stopptd to
give it to him. It was only when the serious hemorrhage occurred
in the sixth stage that he became momentarily unconscious, and it
was then, in a large measure, due to shock and exhaustion.
Sixth Stage. Detachment of the subclavian vein frotfi the artery at
the point of injury after failure to identify the third portion of this vessel
outside of the sca,lenes on accoutit of mass of exudates which masked it
completely. Profuse hemorrhage from the artery at the anastomotic
orifice, in spite of complete control of this vessel at its origin. Final
ligation of the artery on each side of the bleeding-point. Closure of
the venous orifice by suture without obstructing the lumen. — This proved
to be the only critical and dangerous stage of the operation. While
Dr. Gessner controlled the subclavian at its origin I made an effort
to dissect the artery out of the mass of exudates in which it was
embedded ; this was so difficult on account of inextricable anatomical
confusion, caused by extravasation and exudates, that I decided to reach
the artery by following the vein to the anastomotic orifice. A long
forceps was temporarily placed upon the over-distended vein on the
proximal (cardiac) side of the vein and a careful dissection was begun,
following the axillary side of the vein into the mass which covered the
scalenes. While doing this the vein became suddenly detached, and
instantly a flood of mixed arterial and venous blood deluged the field
and compelled immediate concentration upon this point to check the
flow which for a moment appeared to defy all efforts at local compres-
sion with gauze pads and fingers. Vigorous traction upon the loop
around the origin of the subclavian, held by Dr. Gessner, did not
control the bleeding, which evidently came from the vertebral and
other collaterals into the now severed anastomosis.
The bleeding-point could not be easily localized ; some blood was
flowing out of the detached vein, but this was easily controlled by
254 MAT AS,
forceps ; the chief hemorrhage came from the opening in the mass of
exudates covering the scalene. By the application of one finger, and
then another, the bleeding was finally controlled, but the least relaxa-
tion of the pressure immediately allowed it to flow in a gush. With
the finger on the bleeding-point, reinforced by the additional finger
of one of the assistants (Dr. Maes), I made a vertical incision into
the mass by the side of the finger, and succeeded in bringing to view
the aponeurotic edge of the scalenus anticus, which I detached almost
completely from its insertion by cutting into it from the axillary side
on a level with the tubercle ; the muscle was not entirely detached at
its insertion for fear of injuring the phrenic nerve, but the section was
sufficient to allow me to insinuate the right index into the inter-
scalenal space, where I recognized a firm, flat cord, which I took to be
the third portion of the subclavian artery. The vessel was now seized
with a longbladed clamp. I then cautiously removed my left index
from the bleeding-point on the scalene, and had Dr. Maes substitute
his fingers for mine over the orifice, which he did so quickly that no
blood was lost in the exchange. I was then able to trace the sub-
clavian artery from the point where it had been grasped by the forceps
to the posterior surface of the scalene. The artery was found adherent
to the posterior surface of the muscle, the bullet having perforated it
in its central portion. The muscle was interposed like a diaphragm
between the artery and the vein, leaving only a small opening,
scarcely long enough to admit an ordinary lead-pencil through it. By
retracting and pulling on the outer border of the partially divided
scalene, the posterior surface of the muscle could be brought to view,
and the continuity of the injured artery could be established on the
proximal (cardiac) side of the vessel. Another long, narrow bladed
forceps was now placed upon the vessel just beyond the point of adhe-
sion to the muscle, thus occluding the lumen of the vessel on the
cardiac side of the perforation. When this was done, digital com-
pression had been stopped, and we had the satisfaction of seeing that all
bleeding was arrested. A fine kangaroo tendon ligature (Van Horn)
was now applied to the subclavian artery outside of the scalene, and
another (of the same material) to this vessel on the inner side of the
perforation, which had apparently involved three-fourths of the cir-
cumference of the artery. The artery was then divided completely
at the injured point. Fearing that the proximal side of the artery
had not been sufficiently secured, and that the ligature might slip
because it was too close to the divided edge, another ligature was placed
TRAUMATIC A RT ER I O-V ENO US ANEURISMS. 255
almost half an inch beyond the first on the inner side of the scalenus
muscle. In order to do this effectively the divided or free end of
the artery was seized with long-bladed forceps, and was forced to the
surface through the mass of exudates which still covered and filled the
right prevertebral space. The ligated stump then appeared on the
inner edge of the muscle, where it was pulled out and twisted upon
itself, and then ligated, as previously stated, about three-fourths of an
inch from the terminal ligature. This ligature must have been placed
very close to the origin of the thyroid axis and internal mammary,
and the axial rotation, to which the main trunk was subjected, must
have had some effect in occluding the origin of these vessels. It is
possible, also, that by adopting this radical procedure much inter-
ference was caused with the collateral supply furnished by these im-
portant branches, as I can account in no other way for the sloughing
of the hand and arm which followed. I was, however, so profoundly
impressed at the time with the enormous force of the collateral circu-
lation through the vertebral and internal mammary that I would take
no chances of secondary hemorrhage by leaving a single ligature at
the terminal and injured part of the artery. In fact, I would have
ligated the vertebral if the condition of the patient would have per-
mitted of longer delay. After these ligatures had been applied and
the vessel thoroughly secured, the traction loop on the mediastinal
portion of the subclavian was removed.
The subclavian vein, which had now been detached from the mass
of exudates which bound it to the anterior scalene and the arterial
opening of communication, was carefully examined. It was found to
be circular and to involve only a part of the lumen of the vessel.
We, therefore, proceded to suture this orifice, and closed it completely
without occluding the lumen of the vein. After this had been done
the clamp and provisional ligature placed on each side of the sutured
point were removed, and it was noticed that the circulation in the vein
was restored, though the calibre of the vessel was very much reduced
in size, the return flow from the axillary side being very small on ac-
count of the great diminution in the arterial supply of the arm. The
subclavian and jugular veins, which previously had been enormously
distended, now became very flat and much reduced in size, and pre-
sented a very marked contrast to the conditions existing prior to the
ligation of the artery.
The patient's condition had, in the meantime, undergone serious
and unfavorable changes during these long, tedious, and exhausting
256 MATAS,
manipulations. The pulse at 11. 16 was 100; at 12, it was 120; and
at 12.20, when the first great gush of blood followed the detachment
of the vein, it rose immediately to 140. The quality of the pulse,
which had been remarkably good before, now showed the marked
effects of shock, though it remained fairly good. Nevertheless, we
decided to infuse with saline solution, and four and a half pints of hot
salt solution (0.7 of i per cent.) were injected through the m.edian
basilic, which had been exposed and held in readiness for the purpose.
This brought down the pulse to 108 ; but it again grew weak, and
at 2 p. M. was 140 again. In the meantime the patient, who was very
pale and covered with a profuse cold sweat, was made to drink freely
of toddy and given hypodermics of strychnine and digitaline, with
i/ioo gr. of atropia sulph.
Seventh Stage. Readjustment of flap ; closure of wound ; drainage. —
While these restorative measures were being vigorously applied we
attempted to replace the clavicle with the osteoplastic flap (skin,
aponeurosis, sternomastoid) into position, but found that by so doing
it would be difficult to obtain a complete apposition of the soft parts
above the clavicle, and thus leave dead spaces. I therefore decided
to sacrifice the bone for the sake of obliterating all dead spaces, and
removed it entirely from the musculocutaneous flap, to which it was
firmly attached by its periosteal covering. An iodoform gauze drain
was left in the anterior mediastinum, and the flap was sutured into
place by a series of interrupted silkworm sutures.
Eighth Stage. The bullet was extracted by an incision over the
anterior edge of the trapezius, and found to be a 38 calibre and ab-
solutely undeformed. It had not even grazed the clavicle, as I at first
suspected, and had passed upward under the bone without touching
it. This remarkable fact could only be accounted for by the eleva-
tion of the arm when the patient was shot, and while he was holding
his antagonist to the ground.
A large, firm, dry gauze compress was now applied over the field of
the operation, reinforced with an absorbent cotton pad, all being held
by a long spica, which equally compressed the wounded surfaces. In
addition, large broad strips of adhesive plaster were applied over the
bandage and over the shoulder, from the scapular region to the chest,
thus giving additional security to the bandage. The arm, which was
quite cold on the affected side, was now wrapped up in cotton batting
from the fingers to the axilla, the cotton being held in place by a
loose spiral-roller bandage.
TRAUMATIC A RT ER I O-VENO US ANEURISMS. 25/
The patient was perfectly conscious, but completely exhausted and
shocked. He was extremely pale, the pupils moderately dilated, and
the pulse small, and for a few moments after he had been transferred
to the rolling carriage it was very small and scarcely perceptible at the
wrist. He complained of chilly sensations and shivered. After warm-
ing him with hot bags and blankets he was (at 2.45 p.m.) taken to his
bed, when he was given a toddy and copious draughts of ice water, which
he craved incessantly, and which fortunately he never rejected. At
3.45 P.M. he was still extremely weak, almost collapsed; he felt cold
on the surface, but the thermometer in the rectum showed a tempera-
ture of 1031°, At 4.50 P.M. the rectal temperature was 104°, and
half an hour later 104^°. At 10 p.m. his pulse, which at one time
had risen to 150, had fallen to 100, beating regularly, full, and strong ;
his temperature had fallen to loif, and he was resting quietly, but
perspiring profusely as defervescence progressed.
History Subsequent to Operation. The subsequent career of this
patient after the operation was marked by many incidents which de-
layed his convalescence and caused us much anxiety as to the ultimate
fate of his arm, but never gave us serious apprehensions as to his ulti-
mate recovery.
Some idea may be obtained of the tediousness of his convalescence
by noting that he was admitted to the hospital on September 8th
(fifth day after the injury), was operated on September 13th (ninth
day), and was discharged November 12, 1900 (sixty-first day), and
even then his arm had not healed, and he was not entirely discharged
by Dr. Power at his home until April 19, 1901 (158 days after leaving
the sanitarium), when he discarded his last dressings. He was, there-
fore, under treatment a little over seven months from the date of the
operation. It is just to state that this delay in his complete recovery
was caused almost entirely by the sloughing which took place in the
hand and forearm, which followed immediately after the ligature of the
artery. The wound in the neck healed /<?r/r/waw, and never gave us
the least anxiety. With the exception of a stitch abscess it healed with-
out interruption and was entirely well on the twenty-second day, when
all dressings were discontinued in the neck. The necrotic changes that
took place in the hand and forearm are of such rare occurrence after
ligations of the subclavian vessels that they deserve special reference
in this history. My notes in reference to this point read as follows :
"September 14th. Friday, 9 a.m. (the day after the operation),
patient's general condition much improved. Pulse, no; tempera-
Am surg 17
258 MATAS,
ture, 99^°. Patient complains of little pain in region of wound,
which, in addition to copious aseptic dressings and spica bandage, has
been covered with a square flat bag filled with bird shot, weighing
half a pound, to further compress the part and favor the obliteration
of dead spaces.
" The cotton batting and loose bandage are removed from the arm,
and I am painfully surprised to find evidences of complete mortifica-
tion of several digits and parts of the palm of the hand and forearm;
the skin in some places on the ulnar side appears to be necrotic up to
the elbow. Complete insensibility of the entire extremity up to the
bend of the elbow exists. After washing the extremity in hot water
and alcohol, the capillary circulation is found to exist in considerable
areas over the dorsum of the hand, wrist, and forearm ; but the palm
and fingers, especially the little finger and the thumb, appear to be
hopelessly lost. No radial, brachial, or axillary pulse can be felt.
The arm down to the elbow is sound, warm, and sensitive. The hand
is shrivelled, pale, waxy, cadaveric ; here and there a few patches of
capillary extravasation or stains ; no swelling, oedema or violaceous
discoloration ; no signs of venous asphyxia ; the superficial veins,
which before the operation were prominent and turgid, had now be-
come invisible. The mortification is evidently due to arterial ischaemia.
Arm wrapped up loosely in cotton batting and surrounded with hot
bags."
At 3 P.M. the temperature had risen to 101° ; pulse, 136. Evidently
the reactionary changes due to the sloughing were causing the disturb-
ance, because there was nothing in the wound to account for the
change. At 4.30 p.m., pulse 130; at 7.30, pulse 128, temperature
101°, skin moist, general condition excellent. The hand, at wrist
and forearm, is now beginning to show oedema, and there are dry
patches of dark extravasation over the mortified areas. The arm
above the wrist and elbow and in proximity to the dead parts is hot
and presents a dusky red erythematous color.
On September 20th the following observations are recorded : " The
affected arm is still much swollen and oedematous, though the swelling
is now subsiding. The thumb-nail and skin in palmar and dorsal
aspects of the thumb mummified, shrivelled, dry, purplish-black in
color; tip of index finger and nail, black and dry ; ring finger to first
knuckle black ; two large black, dry patches in palm of hand and
base of thumb ; another large black, leathery patch over the entire
hypothenar region. A large blister was formed extending over the
TRAUMATIC A RTE R I O -VENO US ANEURISMS. 259
ulnar and dorsal aspects of the forearm. The arm was treated by
daily washing with hot lysol solution (i per cent.), followed by com-
plete alcohol bath, after which it was thickly covered with an oint-
ment consisting of ichthyol and zinc oxide and vaseline ; over the fore-
arm and arm, where the skin appeared to be red and inflamed, com-
presses of dilute lead and opium lotion were kept constantly applied.
On September aSth I left the city for a month's vacation and trans-
ferred the patient to Dr. Gessner, who continued to attend and dress
him carefully until my return, October 31st, when the following obser-
vations were noted : " General condition excellent ; temperature and
pulse normal ; good appetite ; patient sits up. Wound in the neck
completely healed since September 20th, requiring no dressing. The
most important changes have taken place in the hand and forearm.
The little finger had dropped off, leaving a large granulating surface
in the hypothenar region ; a large granulating surface over the thenar
eminence, where the skin had also sloughed off. The thumb had
sloughed and had to be excised. The first metacarpal is exposed on
the palmar side. A deep palmar tunnel connects the granulating
surfaces on the two sides of the hand. This tunnel in the palm is
caused by the sloughing of the long flexor tendons and some of
the interossei. The ulna from its upper third down to the wrist-
joint is exposed, even the periosteum being lost. Only the styloid
process and articular end are sound and covered with soft parts. All
the pronato-flexor mass of muscles and other soft parts covering
the ulna have sloughed off, leaving a granulating tissue on the peri-
osteum, apparently trying to cover it, A long sinus, caused by the
sloughing of the supinator and extensor muscles and brachialis anticus,
can be traced upward into the lower third of the arm. Four and a half
inches of necrotic ulna were excised with the Gigli saw ; the first
metacarpal was enucleated out of its periosteal shell. The nail and
terminal phalanx of the index were removed ; the gaps in the
palmar side were covered over with dorsal cutaneous flaps. A free
incision was made from the forearm to the arm into the external inter-
muscular septum to remove the sloughs formed by the supinator and
the brachialis anticus ; the musculospinal and ulnar nerves have been
lost in the deep sloughing of the forearm ; there is complete anaes-
thesia of all parts below the elbow."
After this the condition of the arm steadily improved, and the patient
was discharged November 12th in verygood general condition, but still
suppurating through several granulating sinuses. After this his arm
26o MAT AS,
was attended to at his home by Dr. Power, who had to open another
sinus resulting from extension of suppuration in the arm. He also
wrote that the wound in the neck had reopened at one point for a few
days, but had healed without discharging any ligatures.
Finally, when the patient came to see me, April 19th, his arm was
entirely healed and presented the appearance shown in the photo-
graph. He had lost his thumb and little finger, and the remaining
digits were living, but stiff, rigid, and completely anaesthetic. He
has a stiff wrist and a much reduced forearm, the ulna being wanting.
Nevertheless, he has slight supination and pronation, caused by preser-
vation of the biceps tendon, and has fairly good motion at the elbow.
The skin is devoid of sensation up to the elbow.
In closing the description of the case we would call attention to
the following points:
1. That the lesion caused by the bullet was a true aneurismal
varix of the middle third of the subclavian artery and vein just
where the vessels are separated by the musculo-aponeurotic
partition formed by the scalenus anticus.
2. That a continuous direct channel had formed between the
artery and vein through the small perforation in the muscle.
3. The early establishment of a communication between the
artery and the vein was favored in this case by the primary
hemorrhage, which immediately filled up the rigid and unyield-
ing space between the scalenes and forced the artery against the
posterior surface of the muscle, thus compelling the stream of
blood to escape through the small perforation made by the bul-
let, and directing it in the line of least resistance — i.e., toward
the opening in the vein, which was held against the anterior
surface of the muscle by the clot which accumulated in the
space bounded by the scalene, clavicle, and deep cervical
fascia.
4. That the stream of arterial blood in the subclavian artery
had been almost completely short-circuited and was poured into
the proximal or cardiac side of the subclavian vein, which was
enormously distended thereby, the circulation of the upper
extremity being kept up chiefly by the collateral circulation.
5. That a simultaneous contusion and injury of the brachial
TRAUMATIC ARTEKIO -VENOUS ANEURISMS. 26 1
plexus existed, which led to a paralysis of sensation and motion,
which was intensified by arterial ischaimia of the arm.
6. That the dissection and elevation of an osteoplastic flap,
including the inner two-thirds of the clavicle, was most advan-
tageous in securing a free access to the injured parts.
7. That the innominate artery was missing, and in its place an
anomalous subclavian, originating from the arch of the aorta,
existed ; the corresponding common carotid, originating in the
arch on the left side of the trachea, did not reach the surface
until it had ascended to the lower level of the thyroid gland.
8. That the provisional loop of silk applied around the
origin of the subclavian to secure prophylactic hemostasis in
the field of operation failed to control the bleeding from the
proximal side of the arterio-venous orifice when the vein was
detached.
9. That bleeding from the subclavain at' the aneurismal orifice
was only controlled after the artery had been secured by a
double ligature applied on each side of the bleeding-point — i.e.,
on the inner and outer side of the anterior scalene.
10. That in future operations in similar conditions the only
means of securing absolute prophylactic hemostasis (on the arte-
rial side) would be to resort to digital compression over the
subclavian artery at the origin of the vertebral (just below the
tubercle of the fifth cervical vertebra) in addition to the trac-
tion loop of silk applied around the innominate. The applica-
tion of a traction loop on the first portion of the subclavian on the
outer (axillary) side of the origin of the vertebral is a procedure
beset with many difficulties, because of the numerous enlarged and
adherent veins which are matted together in a mass of exudates
and which would flood the field at the least provocation. Digital
compression of the vertebral could be readily and effectively
applied, while the innominate, which as a rule is quite accessible,
would be compressed by the traction loop.
11. That it is possible, as shown by this case, to restore the
continuity of the subclavian vein by lateral suture after detaching
it from the aneurismal orifice.
12. That the possibility of mortification of the peripheral
2^2 MATAS,
part of the extremity must not be overlooked in considering
the prognosis and post-operative results.
13. That this ischaemic necrosis of the extremities is more
liable to occur when the subclavian is subjected to torsion in its
second division, thus probably obliterating or injuring the orifices
of the thyroid axis, vertebral and other branches.
14. That the partial mortification of the hand and forearm in
this case, while traceable directly to the arterial ischaemia, was
probably favored by the defective innervation of the parts from
injury to the brachial plexus.
15. That a notable feature of the sphacelation was that it
especially involved large muscular groups rather than the over-
lying skin, thus confirming the observations of Lesser, Volk-
mann, Ludwig, Bernays and others on the degenerating and
necrobiotic effect of arterial ischgemia upon muscular tissue.
16. That the advantages of massive infiltration with very
dilute eucain and cocain solutions were well shown in this case,
as they economized the use of the general anaesthetic and per-
mitted not only the painless resection of the clavicle, but also
facilitated the exploration of the deep cervical bloodvessels
while applying a traction loop of silk around the anomalous
subclavian at its origin.
17. That when a general anaesthetic becomes necessary,
chloroform, preceded by morphine, is, in these cases, better than
ether, because it is not accompanied by as much respiratory
disturbance and overdistention of the veins.
18. That the experience of the author in this case confirms
his previous observations and those of others (Gushing, LiH-
enthal, Jaboulay, etc.) to the effect that the preliminary admin-
istration of morphine, followed by local infiltration, apparently
predisposes to the favorable and economical administration of
chloroform, which, in this case, was never pushed to absolute
unconsciousness.
Historical Data.
The history of arterio-venous aneurism clinically begins with
the first accurately recorded case, described by William Hunter
TRAUMATIC ARTERIO -VENOUS ANEURISMS. 263
in 1757, and anatomically by the description of Delacombe in
1761, which was based on the post-mortem study of a lesion im-
plicating the femoral vessels (Broca). The first accurate account
of arterio-venous aneurism of the subclavian vessels dates back
to the classical case of the Sargent Pierre Cadrieux, whose in-
jury was treated by the distinguished Dominique J. Larrey in
1829. and made memorable by his admirable description of this
condition in his Cliniqiies Chirurgicales, Paris, 1829, vol. iii. p.
115.
From 1829 to the present time we have been able to gather
the records of 15 cases of arterio-venous aneurism, including
our present observation. The recorded traumatisms of the sub-
clavian vessels are rare, not only because these vessels are well
protected by the clavicle, and are not so much exposed to injury
as those of the extremities, but chiefly because accidental injury
to these vessels is so liable to a promptly fatal termination
from associated complications, and the profuse primary hem-
orrhage and shock, that the patients do not survive long
enough to be subjected to any form of surgical treatment.
Nevertheless, in 1877, Von Bergmann was able to collect 90
recorded instances of injury (gunshot and stab) of the subcla-
vian vessels. Rotter, of Berlin, as near to us as 1893, was able
to collect only 14 cases of stab wounds of the subclavian ves-
sels ; and Souchon, in his remarkable essay on the surgery of
the subclavian artery, published in 1895, was able to collect only
14 cases of arterial traumatic aneurisms, all involving the third
division of the right subclavian.
Our collection of 15 cases of arterio-venous aneurisms, gath-
ered from all sources in the literature, are all traumatic, and in-
clude injuries to the vessels on either side, irrespective of the
topographical division of the artery involved, though, in a large
majority of these, the precise point of injury could not be ac-
curately ascertained.
The cases are reported in chronological order by the follow-
ing observers: (i) Larrey (D. J.), Paris, 1829; (2) Sanson, quoted
by Robert, Paris, 1832; (3) Berard, quoted by Richet, Paris,
1842; (4) Wattmann, Vienna, 1843; (5) Wederstrandt, New
264 MATAS,
Orleans, 1854; (6) R. W. Smith, Dublin, i860; (7) Fischer,
Gottingen, 1861 ; (8) Letenneur, Nantes, 1861 ; (9) Will (J. C.
Ogilvie), Glasgow, 1875; (10) Kirsch (B.), Breslau, 1875; (il)
Arango (A. P.), Medellin, Spain, 1880; (12) Rotter (J. V.),
Berlin, 1893; (13) Wedekind (G.), Berlin, 1893; (14) Veiel,
Cannstadt ; (15) Matas, New Orleans, 1900.'
The reports of these cases, together with the comments of
the authors and the important discussions which followed the
presentation of several of these to various medical societies, fur-
nish the available data upon which the special history of this
rare, interesting, and serious lesion is based.
Analysis of Cases.
An analysis of these 15 cases furnishes the following points
of interest :
{a) Nine were caused by stab or penetrating cut wounds ; 6
by bullets.
{b) All the patients were men.
{c) The injuries were almost all inflicted upon comparatively
young subjects. Of the 9, whose ages are distinctly specified,
the oldest was thirty-two years of age at time of the injury; the
youngest fifteen years. In six cases the ages are not specifically
stated, but the evidence would point to the fact that none had
exceeded the middle period of life.
(d) In 6 cases the vessels on the left side were injured; in 7,
those on the right; in 2, the side injured is not stated.
{/) The seat of injury was absolutely demonstrated to be in
the subclavian vessels in 7 (Wattmann's, Wederstrandt's, Will's
Rotter's, Wedekind's, Veiel's, Matas'), either by autopsy or
operation.
(/) In all the cases but 2, in which the seat of the lesion is
either positively or approximately stated, the third division out-
side the scalenus was implicated. In Letenneur's case injury
1 To these fifteen cases two more should be added, viz., Reboul's, Montpellier, 1894,
fatal, not operated; Vallas', Lyons, 1900, fatal, operated: both caused by indirect frac-
ture of the clavicle; in all, seventeen cases.
TRAUMATIC ARTERIO -VENOUS ANEURISMS. 265
of the first division was suspected. In the author's, the second
division was positively involved.
In the 8 other cases the diagnosis of injury of the subclavian
vessels was confirmed by the seat of the external lesion, course
of weapon, and range of the missile, the tumor, the immediate
effect upon the circulation of the arm, and the other physical signs,
showing that the subclavian trunks, and not their branches, had
been injured.
In 5 of the 15 cases the brachial plexus was coincidently
and partially injured; positively in 3 (Larrey's, Wederstrandt's,
Matas); probably in Letenneur's and Kirsch's cases. In several
cases, in which reference to the condition of the arm is made, the
disability of the arm was pronounced, but was either due to pri-
mary or secondary vascular disturbances (Wattmann (secondary),
Smith, Arango, Wedekind, Veiel).
Primary circulatory or neural disturbances may have existed
in other cases, but this cannot be stated from the published
reports.
The //wz^ after the injury, when the first sign of arterio-venous
aneurism was first recognized, is stated in 8 out of the 11 un-
operated cases ; in 3 it is only approximated ; in i the charac-
teristic thrill and murmur were apparently altogether missing
(Will's case); in 3 no information on this point can be obtained.
In I (Matas') the signs of arterio-venous communication were
established within four hours after the injury; in 3 cases they
were present on the second day (Larrey, Wederstrandt (?), Rot-
ter) ; in 3 the diagnosis was made on the third day (Letenneur,
Kirsch (?), Wedekind ; in i on the sixth day (Fischer (?) ) ; in
I on the eighth day (Arango); in i on the ninth day (Veiel);
in I "a few days later," after the injury (Berard's case). Apart
from injury to the brachial plexus and purely vascular disturb-
ances in the arms complications are noted in Wattmann's case
(secondary phlegmonous inflammations of arm) ; in Will's (septic
hemopyothorax) ; in Wedekind's (septic phlebitis and pneu-
monia). In only 3 of the 15 cases did secondary hemorrhage
follow after the primary injury, and these were all stab wounds
(Will, R6tter, Veiel).
266 MATAS,
Results in Unoperated Cases.
Of the 15 cases 11 were treated expectantly, and of these i
died from secondary hemorrhage and septic comphcations three
weeks after the injury, and after the external wound had healed
(Will's case). The remaining 10 all survived the immediate
effects of the injury, their wounds healing after the cessation
of the primary hemorrhage.
Only 4 out of the 15 cases were operated upon; in 3 of
these (Rotter, Veiel, Matas) within twelve days after the in-
jury, and all recovered ; in i (Wattmann's case) thirty-two
years after the primary injury, when the ligation of the sub-
clavian was necessitated by urgent aneurismal complications,
and this was the only fatal case. The total mortality of the
entire group is, therefore, 2 : 15, or 13^ per cent/
An investigation of the individual records as far as they are
available shows the following results as regards the final out-
come of this injury on the vessels and upon the affected arm :
1. In Larrey's case (sabre cut) four years after the injury there
was marked diminution in the aneurismal signs, but the arm
was disabled completely by paralysis, contracture of fingers
and hand, the pulse in the brachial and radial vessels sup-
pressed, and the circulation in the superficial veins obliterated.
2. Sanson's patient (gunshot), quoted by Robert, was living
ten or more years after the injury, but still annoyed by a loud,
purring murmur (ronflement) and other active signs of aneu-
rism, which could be heard at a distance, and for which he
consulted Sanson.
3. Berard's case, quoted by Richet (stab), left the hospital
" several weeks " after the wound had healed, but complaining
of the annoyance caused by the disturbing noises in the aneu-
rism. These seemed to exasperate him, and he clamored for an
operation, which neither Berard nor Dieffenbach would perform.
4. Letenneur's patient (small pistol shot) healed, with persist-
ence of all the aneurismal signs, but felt well and was able to
1 If we add the two fatal cases of Reboul and Vallas the mortality is increased 4 : 17,
or 23^"- per cent.
TRAUMATIC A RT E R I 0-VENOUS ANEURISMS. 267
take his first promenade twenty-one days after the injury, after
which no further observations are recorded.
5. Wederstrandt's patient (shot) recovered from his injury,
and died at the Charity Hospital seven years after from diar-
hcea. He had marked aneurismal symptoms, with paralysis
and atrophic changes in the arm, up to the time of his death,
and at the autopsy a well-marked varicose aneurism between
the subclavian artery and vein was found.
6. Fischer's case (stab) recovered from the injury, with per-
sistent signs of aneurism, but was living one year after the
injury, after which he passed out of observation.
7. Kirsch's patient (shot) recovered from the immediate effects
of the injury, remained under observation two and one-half
months, but was not improved, and was discharged with active
aneurismal signs. He suffered also from persistent disturbances
in the circulation, and innervation of arm and hand ; had diffi-
culty in moving his fingers.
8. Smith's patient (stab) recovered from the immediate effects
of the injury, the wound healing in three weeks. Signs of vari-
cose aneurism existed seven months after the injury, with dis-
turbances in the circulation of the arm under certain conditions.
Eight months (?) after the injury he was compelled to return to
the infirmary, with signs of obstruction in the circulation of the
arm. The arm on the affected side had suddenly become cold
and oedematous, and in a few days gangrene of the ring and
little finger, with part of the forearm and hand, had set in. He
gradually recovered from the sloughing without serious consti-
tutional disturbance. The radial pulse, which had ceased to
beat from the time of the injury, now, strange to say, returned,
when gangrene was established. The aneurismal signs still
persisted actively when discharged.
9. Arango's patient recovered from the immediate effects of
the injury, which was accompanied by marked circulatory dis-
turbances in the arm, but no sloughing. He was so much dis-
turbed by the noises in the aneurism that he had to be carried
to the vicinity of a torrent in order to drown the sounds and
thus secure sleep. This intense disturbance subsided in forty
268 MAT AS,
days. Two months afterward the aneurismal signs continued,
though much diminished. Ten years later, the patient's friends
reported him " feeling perfectly well."
10. Will's patient (stab wound of subclavian vessels compli-
cated by perforation of pleura) was stabbed on May 7, 1875 ; left
hospital on 19th, had first secondary bleeding while travelling;
on 25th, last and fatal hemorrhage. Patient expired as the
operator had begun an incision to expose the bleeding vessel
11. Wedekind's patient (stab) recovered from the immediate
efTects of the injury and was in excellent general condition
seven months after, but the aneurismal signs remained una-
bated, and he suffered, under special conditions, from transitory
disturbances in the sensibility of the arm and hand, caused
apparently by interference with circulation.
Under the category of unoperated cases we could also prop-
erly include Wattmann's case. This case is most interesting as
showing that even after a latent period of thirty-one years, in
which the patient was apparently well, the lesion finally became
active and gave rise to fatal complications.
Thus we find that in ii out of 12 cases which were treated
primarily by the expectant plan, 1 1 recovered from the imme-
diate effects of the injury, and their wounds healed without
secondary hemorrhage, except one (Will's case), by simple
measures of compression with bandages, rest, etc. But it is to
be noticed, also, that only in one or possibly two (Larrey and
Arango) was there reason to believe that the lesion had been
cured. In all, the signs of arterio-venous aneurism remained
active, and in several the murmurs and sounds, after many years,
were so annoying that the patients applied for relief on this ac-
count— in one case more than ten years after the injury (Sanson's
case). In six cases (Larrey, Kirsch, Wederstrandt, Smith,
Fischer, Wedekind) permanent circulatory and trophic disturb-
ances persisted in the arm, not only from associate injury to
brachial plexus, but from interference with circulation ; in one
(Smith's case) gangrene set in, with loss of part of the extremity
(fingers, hand, and forearm), more than seven months after the
patient had recovered from the injury. In the other unoperated
TRAUMATIC ARTERIO -VENOUS ANEURISMS. 269
cases, with the exception of three (Wattmann's succumbed thirty-
two years afterward, after thirty years of latency; Will's died from
secondary hemorrhage three weeks after the injury, and Smith's,
from gangrene of extremity seven months after), it is only fair to
state that the abnormal conditions of the circulation created by
this lesion were, with the exception of the annoyances and dis-
turbances previously referred to, fairly well tolerated, and were
not incompatible with a long survival and active life. It is well
to note, however, that in at least six of these cases the patients
were last seen, or passed out of the observation of the surgeons
who reported them, within a few weeks or months after the in-
jury, while the lesion was still active, and too soon to permit
any definite conclusions as to the final outcome of the injury
(Berard, a few weeks; Smith, seven or eight months; Fischer,
one year; Letenneur, twenty-one days; Kirsch, two and one-
half months; Wedekind, seven months).'
The Operated Cases and Results.
In 4 only of the 15 cases was an operation resorted to; in 3
cases ligation of the vessel was made imperative by the occur-
rence of violent secondary hemorrhage following shortly after
the injury, and in only i (my own) was the operation deliber-
ately performed in anticipation of future complications. Three
out of these 4 cases permanently recovered except Wattman's
patient, operated in 1840, who died of secondary hemorrhage
twenty-three days and thirteen hours after the ligation of the
third portion of the subclavian. This case, which is often
referred to as a case of traumatic aneurism of the subclavian
artery at its junction at the axillary, is especially interesting to
us in this connection, because it illustrates the possible transfor-
mation of a passive and benign arterial varix into a rapidly
growing and malignant aneurism of the artery after a long lapse
of time. In this case a gunshot injury was inflicted in 1809
from which the patient recovered without any great disturbance
except cramps in the arm. From 1809 to 1840, thirty-one years,
during which the patient was engaged in active military service,
he suffered no serious inconvenience. In 1840 an aneurismal
2/0 MAT AS,
tumor was developed for the first time under the clavicle. This,
however, did not enlarge for two years. In 1842 erysipelas and
phlebitis set in, and the tumor rapidly grew to threatening pro-
portions. Under these conditions, Wattman found it necessary
to operate. Two ligatures were applied between the scaleni
and the tumor, none to the vein ; secondary hemorrhage oc-
curred at the point of ligature, which caused the death of the
patient. A large varicose sac was found at the post-mortem,
which communicated with both the artery and vein.
In Rotter's case (1892) the signs of arterio- venous aneurism
developed almost immediately after a stab injury; profuse pri-
mary bleeding followed. Rotter advised immediate operation, but
the patient would not consent until after a nearly fatal secondary
hemorrhage occurred on the ninth day at midnight, when Rot-
ter cut down upon the vessels and ligated them outside of the
scalenus after resecting the clavicle. The knife had penetrated
one inch below the middle of the left clavicle, causing a sharp-
edged oblique wound, two-thirds of an inch long. After re-
secting the clavicle and displacing it upward, he was able, by
following the track of the wound, to insinuate his fingers behind
both vessels as they emerged on the outer side of the scalenus,
and by hooking his fingers behind them and dragging them
forward was able to control the bleeding until the artery and
vein had been ligated above and below the point of injury. The
patient, though much shocked, made a good recovery. The clavi-
cle was sutured back into position. The arm became cadaveric-
ally pale and cold, but the circulation was finally re-established.
Veiel's case is also very interesting ; the patient, aged twenty-
three years, was stabbed in the right shoulder on May 14. 1894.
Wound one-third of an inch below the middle of the clavicle.
Profuse hemorrhage and syncope when bleeding stopped spon-
taneously. Temperature, about 103°, gradually subsiding to
normal on the ninth day. Profuse secondary hemorrhage took
place at midnight(ninth to tenth day) while the patient was asleep.
He had signs of arterio-venous aneurism, which were observed
for the first time on the tenth day, when septic pneumonia set
in. Fearing the repetition of the hemorrhage, which would
TRAUMATIC A KT E R I O-V E NO US ANEURISMS. 27I
have been fatal, an operation was performed. Following the
track of the wound an incision was made into a pocket situ-
ated below the clavicle, but a flood of blood followed which
could only be controlled by packing the cavity. While this
was being done the third division of the subclavian was exposed
and ligated outside of the scalenes, but upon diminishing the
pressure and removing the pack in the wound below the clav-
icle, bleeding followed, which was not controlled until the vein
had been exposed and ligated in the sac above and below the
injury. A third tributary vein, which continued to bleed freely
after the main trunk had been secured, had also to be ligated.
Hsemoptysis and pyaemic pneumonia, with temperature of 104°,
threatened the life of the patient for several days. Fever ceased
only on the twenty-fifth day after the injury, and only after a
large phlebitic phlegmon of the arm on the affected side had
been opened and a septic venous clot removed. The wound
had healed and the patient was discharged two and a half
months after the operation in a very satisfactory general condi-
tion. The circulation in the arm and its nutrition were affected
permanently and very seriously. Eight and a half months
after the operation anaesthesia and trophic changes, with a
loss of thermic sense, existed, leaving the arm in a state of
functional disability.
These four operated cases (including my own fully reported
in the first section of this paper) resulted in three recoveries,
the only death (Wattmann's) being due to secondary hemor-
rhage following a ligature applied under very disadvantageous
conditions and with the old septic technique. In 2 out of the 3
cured cases serious functional disability followed after the inter-
vention, though in my case, in which partial gangrene of the hand
and forearm occurred after operation, there was a coincident
paralysis of the arm from injury to the brachial plexus.
Effects of the Arterio-venous Lesion of the Subclavian Vessels
upon the Circulation of the Upper Limb.
The effect of accidental and surgical occlusion of the sub-
clavian vessels upon the circulation of the arm is the cause of
2/2 MAT AS,
much concern in these cases. In analyzing the individual re-
ports of these fifteen arterio-venous injuries or aneurisms we
are impressed by the fact that in a large majority the effects of
the arterial ischaemia and coincident venous obstruction were
immediately perceived. Suppression of the brachial and radial
pulse are noted in the majority of the cases of which full obser-
vations have been recorded; in many, great pallon lividity of
the skin, ecchymoses, coldness of the surface, functional dis-
ability, numbness, parsesthesia, oedema, etc., are recorded as the
immediate effects of the injury. In two, extensive interference;
in one of these spontaneously (Smith's case); in the other, after
the ligation of the artery and lateral suture of the vein (Matas).
That the danger of sloughing is not to be lightly considered is
well shown in my case, in which, after the ligature of the second
division of the artery, followed by torsion of the proximal end
(following VVyeth's suggestion), and after simple lateral suture
of the vein purposely done, so as not to interrupt the venous
current, complete arterial ischaemia followed, causing an exten-
sive dry sphacelation of the several fingers, part of the hand,
and forearm. That this was due to complete interference with
the arterial and not the venous supply of the limb is proven by
the character of the gangrene (dryj and pallor of the skin. This
result is important because the ligation was performed with the
most aseptic technique and with absorbable kangaroo ligatures,
and the wound healed per primam. The complete ischaemia of
the arm can only be accounted for by the torsion which was
applied to the proximal end before ligation, which no doubt
interfered with the collateral supply from the branches of the
thyroid axis, superior intercostal, and possibly the internal
mammar)^ This extra precaution, which was calculated to
diminish the risk of secondary hemorrhage, should be avoided
if possible in future operations.
We have already referred to the tropho-paralytic phenomena
which in some cases permanently impaired the usefulness of the
arm as a result of circulatory disturbances independently of in-
jury to the brachial plexus (Veiel's case is probably the most
notable in this respect). That the danger of sloughing is
TRAUMATIC A RT E R I O-V EN O US ANEURISMS. 273
greater in double (arterio-venous) injuries than after interfer-
ence with arterial circulation alone is well shown by the com-
parative statistics of the two classes of injuries. Le Fort, in
his learned and careful study of 223 ligations of the subclavian
artery for all causes (published in 1867), was able to find only 4
cases in which gangrene occurred, and this was limited chiefly
to the fingers (1.7 per cent.). These are the cases reported by
O'Reilly, White, Blizzard, Terrier, the last complicated by in-
jury to the brachial plexus. Von Bergmann (1877), ^^ studying
the effects of injury to the subclavian from the same point of
view, states that in 90 cases of ligation of the subclavian, gan-
grene of the fingers occurred in 3 cases- (3;} per cent.), and in
these this result was attributable largely to the extensive con-
tusion of the skeleton and soft parts about the shoulder girdle.
In this respect the risk of gangrene cannot compare with the
greater frequency of this result in similar ligations of the vessels
at the groin.
It is also well established that gangrene is much less frequent
after ligations of the third division of the subclavian above the
clavicle than after the ligation of the axillary when this is done
in the wound.
For instance, Le Fort {/oc. cit.), in a study of 42 cases of
axillary aneurisms, notes 5 cases in which gangrene occurred
as a direct result of the traumatism without ligation, and in 6
in which the gangrene followed the ligature applied in the
wound at the time of injury.
The gravity of the double (arterio-venous) injuries of the
subclavian vessels from this point of view will now be appre-
ciated when we recall the facts gathered from our statistics that
I in II unoperated cases sloughed (9 + per cent.), and that in
I of the 4 operated cases (25 per cent.) this unfortunate result
followed.
The extent of the traumatism in the operated cases was, it
must be remembered, greater than in the non-operated, since
the operation in 3 of the 4 was necessitated by secondary
hemorrhage or other grave complicating lesion, whereas second-
ary hemorrhage occurred in only i of the ii unoperated cases.
Am Surg i8
2/4 MATAS,
To summarize the liability to gangrene, grossly stated and
without reference to special modifying conditions, it would be as
follows for the various lesions: Arterio-venous injuries of both
subclavian vessels (artery and vein), including ligations, 13.5 per
cent. ; after ligature of subclavian artery (third division) 1.7 per
cent. (Le Fort); or 3^^ per cent, (von Bergmann) ; after obliter-
ative injuries of the axillary, 26.8 per cent. This last per-
centage relates, however, to cases reported before 1867, and
would no doubt be much improved by later statistics ; the con-
trast between the axillary and subclavian injuries is, neverthe-
less, significant.
Practical Concbisions.
As a result of the study of the arterio-venous aneurisms of
the subclavian vessels which we have summarized in this con-
tribution, we find that this class of injuries can be separated
clinically and surgically into three distinct and well-defined
groups:
1. The immediately fatal cases in which death follows so
quickly after the injury from the effect of the primary hemor-
rhage and shock that no effective surgical assistance can be ren-
dered. These probably constitute the largest proportion of cases,
especially in military practice, though an exact estimate cannot
be obtained. It is also probable that the vast majority of inju-
ries involving the first and second divisions are fatal primarily,
and are to be included in this group, except when the injuries
are caused by small projectiles or sharp-pointed weapons.
2. In this second group, primary hemorrhage may be very
great, but spontaneous or temporary haemostasis occurs in the
syncopal state, which favors the formation of a provisional
thrombus. In this class of cases two events may occur which
will profoundly modify the prognosis. In the one case {a) sec-
ondary bleeding will set in within a few hours or, more often,
days (usually within the first week), with disastrous conse-
quences, unless the patient is rescued by prompt operation or
other form of intervention. The other alternative (/;) justifies
the formation of a separate group.
TRAUMATIC A RT ER I O-V E N O US ANEURISMS. 2/5
3. In this group the primary hemorrhage may also be exces-
sive, but, as a rule, is moderate and is readily controlled by press-
ure, or may be spontaneously arrested as in group 2. More
often there is no syncope, because the external hemorrhage is
slight. There may be a large haematoma. No secondary
hemorrhage occurs, the wound heals up, leaving a well-defined
and permanent arterio-venous aneurism.
The arterio-venous circuit is usually promptly established by
direct inosculation between the artery and vein (aneurismal
varix), or by means of an intermediary sac (varicose aneurism),
the fistulous communication between the vessels acting in both
cases as a safety-valve by which the dangers of further extrava-
sation are to a large extent permanently avoided.
Rotter, in his paper published in 1893, analyzes 13 cases of
stab wound of the subclavian vessels, 5 of which were arterio-
venous, including the one which he reports, in which he oper-
ated for secondary hemorrhage following an injury to both
vessels.
He found that in 6 cases the hemorrhage was spontaneously
arrested, and no secondary hemorrhage occurred ; but in all of
these secondary traumatic aneurism developed, which impaired
the usefulness of the arm, either partially or completely, and
led to grave secondary complications which subsequently im-
perilled life.
In seven cases, the larger number, repeated secondary hem-
orrhage occurred, and the result was far more serious, for
all these patients except Rotter's (an arterio-venous injury)
died, and this one was saved only by prompt and desperate
operation undertaken at midnight. As a result of this inquiry.
Rotter advocates immediate operation — i. e., ligation of the in-
jured vessels at the bleeding-point as quickly as possible after
the patient has recovered from primary shock and hemorrhage
without waiting for the appearance of the secondary hemor-
rhage which might prove fatal. The only objection to Rotter's
recommendation is that it is based upon the observation of
mixed arterial and arterio-venous injuries, and not sufficient
stress is laid upon the more favorable tendency displayed by the
276 MAT AS,
arterio-venous injury when these show an early disposition to
form aneurismal varices.
The relative benignity of arterio-venous aneurisms when fully
developed — i. e., when the communication between the artery
and the vein has become distinctly and permanently estab-
lished— has led, as Poinsot correctly remarked in 1882, to the
general acceptance of a fallacious doctrine that in wounds of a
single vessel, such as the subclavian artery, the simultaneous
lesion of the satellite vein was a safeguard to the life of a
patient.
For instance, Moore/ in commenting upon Larrey's case,
said " his [the patient's] life appears to have been saved by the
singular circumstance that the vein was also pierced by the
lance [sabre], which wounded the artery. The blood from the
latter vessel, when restrained from passing through the ex-
ternal wound, escaped into the vein, and was thus saved to the
system until the wound healed." The explanation, says Poinsot,
is as fantastic as the pretended benignity of the injury is con-
testable.
If the simultaneous lesion of the artery and vein is appar-
ently less dangerous statistically than injury of the artery
alone, this is due to the fact that in many immediately fatal
cases the existence of the double injury is not recognized until
after death or only in the cases in which the patient survives
and the anastomosis has had time to form or an operation has
been performed for repeated hemorrhage. Whatever the doubts
entertained on the subject, the cases of Will, Rotter, and Veiel
alone suffice to prove that the old teaching as to the relative
benignity of double injuries is not to be trusted. One fact, how-
ever, must be admitted, as we have conclusively shown in our
table, and that is that once the arterio-venous connections have
been firmly established these injuries as a class are less danger-
ous to life than the traumatic aneurisms involving the artery
alone.
In dealing with these cases practically there are three ques-
1 Holmes' System of Surgery. Edit. 1894.
TRAUMATIC A RT E R I 0-V ENO U S ANEURISMS. 2/7
tions that now present themselves for discussion or considera-
. tion :
I. What is the best treatment that can be applied to arrest
the primary bleeding at the time of injury?
2 After the arrest of the primary hemorrhage, and the
patient has rallied from the shock, and it is evident that one or
both vessels have been injured, shall we proceed immediately
to secure the bleeding-point or wait for future developments,
hoping that the wound will heal ; that no secondary bleeding
will occur, and that if it is a double injury a permanent arterio-
venous communication will be established?
3. After the existence of an arterio-venous aneurism is fully
established and the wound has apparently healed, shall we con-
sider the patient out of danger and discharge him with this
lesion in an active state, trusting to Nature's tolerance of this
condition and to the remote possibility that it may be spon-
taneously cured ?
We may now briefly summarize our conclusions on these three
points seriatim :
The treatment of arterio-venous injuries of the first division
of the subclavian need scarcely be considered. The cases of
survival after the immediate effects of such an injury must be
rare indeed. Nevertheless, wounds inflicted by very small
calibre bullets (Lettenneur's case) or with narrow-pointed
weapons may give rise to comparatively small hemorrhages
which, being spontaneously arrested and circumscribed, will end
in aneurismal varices. It is quite possible that in future cases
of this kind in this locality may be more frequently recorded
than in the past, especially since the introduction of hard, small
calibre projectiles in modern warfare. It is evident that in this
division of the artery no operative treatment is permissible, the
danger and magnitude of the intervention overshadow the pos-
sible danger of the lesion, which, when reduced to the condi-
tion of a simple varix, is undoubtedly compatible with a long
tolerance and survival.
In dealing with arterio-venous traumatisms of the second and
third divisions of the subclavian the conditions are different.
278 MATAS,
Here the vessels are comparatively accessible, and notwith-
standing the grave and formidable character of the undertaking
it is quite possible after the resection of the clavicle, as first
suggested by Langenbeck, and practised by Bergmann, Rotter,
Halsted, the author, and others, to bring the vessels into view
and to ligate them.
In dealing with the first condition — /. e., a bleeding patient —
it is evident that all attempts at radical operation on the spot
cannot be considered in ordinary circumstances. The first in-
dication, then, is to arrest the bleeding, and this is best done
by (i) digital compression over a compress or in the wound,
(2) by packing the wound, if it is a penetrating cut, and holding
the pack firmly wedged in the wound by suturing the edges of
this over the pack ; or, again, (3) by hermetically sealing the
wound with a continuous stitch, as Rotter suggests. This pro-
cedure, followed by a firm compression bandage, will usually
suffice to arrest the external bleeding until the patient is taken
to a hospital or other convenient place, where a flat bag, filled
with lead-shot, and held over the injured area with an elastic
bandage, will usually prevent any further primary (external)
bleeding.
After the patient has rallied from hemorrhage and shock, then
the question arises, Shall we operate and when ? Shall we wait
for a dangerous, if not fatal, secondary hemorrhage to occur, or
prevent this by operation? On this point there are differences
of opinion. No one will question the propriety of early inter-
vention in cases of arterial injury with the formation of a large,
increasing and pulsating haematoma. Here the general princi-
ples which have guided the surgeons in the past are applicable
with still greater reason. The wounded vessels must be sought
for at the bleeding-point if possible. Bergmann's rule in refer-
ence to subclavian injuries, confirmed by Le Fort and Poinsot,
and more recently emphasized by Rotter, in reference to arterio-
venous injuries, has now become a command in this class of
cases.
" The ligature of the artery should be performed as soon as
the patient has recovered from shock; if possible on the day of
TRAUMATIC ARTERIO -VENOUS ANEURISMS. 279
the injury; and the vessel should be secured in the wound and
tied above and below the injured point" (Rotter). While we
recognize the great force of a surgical canon which is based
upon sound reason and experience, it must be recognized, with
Wedekind and other recent writers, that there are conditions
which justify delay, more especially in those cases in which the
subclavian wound implicates both vessels.
It must be recognized that even a reasonable suspicion or
positive evidence of an injury to both vessels (artery and vein)
is not sufficient to justify a suspension of the above stated rule
of practice, but that the development of positive signs of an
established arterio-venous anastomosis does justify delay when
the patient can be kept under constant observation and intelli-
gent supervision. But as the signs of arterio-venous anasto-
mosis are often delayed, other criteria must be depended upon
to decide the question of intervention or abstention. Of
these modifying conditions, the following are probably the
most important :
I. The quantity of blood lost in the primary hemorrhage
whether profuse, moderate, or small. 2. The extent of the sub-
cutaneous haematoma. 3. The fact that the hemorrhage was
arrested with difficulty, or ceased spontaneously and completely,
after syncope. 4. The tendency to recurrence of early inter-
mediate hemorrhage, " warning hemorrhages," which are the
invariable precursors of the more formidable and fatal second-
ary hemorrhages. 5. The development of positive signs of an
established arterio-venous communication.
If the primary hemorrhage is profuse and obstinate ; if it tends
to recur with the restoration of the circulation after shock; if the
hrematoma is extensive and progressive, then there can be no
hesitation as to the urgency of surgical action, whether the evi-
dence points to a single or a double injury of the associated
vessels.
If, on the other hand, the primary bleeding is moderate and is
readily controlled by pressure, or ceases spontaneously and com-
pletely, and there is no extensive or progressive hrematoma ; if
there is no tendency to bleeding upon the removal of the dress-
28o MAT AS,
ings, then delay,/, e., armed expectation, is permissible. If, in
addition to the favorable signs, there is an early development
of the signs of an arterio-venous anastomosis, then a conserva-
tive attitude is more than ever justifiable, /wf/V/^^/, always, that
the patient can be kept under competent and skilled surgical
surpervision (Wedekind).
As to the last point, it is evident that even under the most
favorable conditions, and with the most skilful assistance, the
ligation of a wounded subclavian is a formidable undertaking,
always fraught with great danger, and demanding for its succes-
ful accomplishment all the resources of the technique and the cool
judgment which come only with long training; and if these are
wanting at the time, it is plain that expectancy and palliation,
with pressure, rest, and ice, is the only conservative course to
pursue until the patient has rallied sufficiently to be transported
to a place where the necessary conditions for a radical operation
can be obtained.
Finally, if the patient survives the first hemorrhage and
shock, and there is no recurrence of hemorrhage, and the
wound heals, with the formation of a simple aneurismal varix,
what is the proper course to pursue ? On this phase of the
subject it may be safely asserted that the consensus of surgical
opinion first formulated thirty-six years ago, when Letenneur's
case was discussed at the Societe de Chirurgie, 1867, has crystal-
lized-in definite form in favor of nonintervention.
The statistics which we furnish in this paper — the most com-
plete list of the reported instances of this rare lesion which has
thus far appeared — tend to confirm the arguments of the "let-
well-enough-alone" policy, in so far as they demonstrate that in
at least ii of the 15 cases the patient survived the immediate
effects of the injury and of the arterio-venous aneurism that fol-
lowed it for variable and often long periods of time. The study
of these cases shows, however, that while the active persistence
of the lesion is compatible with a long survival (ten years in two
and as long as thirty-two years in one), they also show that in
the vast majority (all buttwo)the lesion persisted in an active state
in spite of sustained efforts to cure it ; in many, the final outcome
TRAUMATIC A RT E R I 0-V ENO US ANEURISMS. 281
could not be ascertained, but in others disastrous consequences
followed in consequence of disturbances of the circulation in the
extremity, which shows that arterio-venous aneurisms of the sub-
clavians,like those of other large trunks, persist as pathological
conditions, which are only tolerated by the organism , and remain
a vulnerable point in the vascular system, which may lead — even
after years of toleration — to disaster and death. These facts
alone would justify a more aggressive attitude toward this form
of vascular lesion on the part of sufgeons were it not that the
dangers of the operation required to eradicate it are not to be
underrated, even with all the advantages of the modern technique.
In conclusion, while recognizing that a decision in this matter
must rest largely with the personal equation and experience of
the operator, we believe that in all fully established arterio-
venous aneurisms which are well tolerated and give rise to little
disturbance — and are presented by patiertts who can be kept
under periodical observation — the old rule of non-intervention
is still in order and should be followed. On the other hand, we
believe, with Delbet, that with the improved conditions of the
present day the indications for interference have broadened, and
that whenever the lesion is not well tolerated, and gives rise to
serious circulatory or other disturbance, it is justifiable to operate
with the view of extirpating the lesion, especially when situated
in the more accessible third and second divisions of the artery.
In addition to the references given in the table of cases, the
following texts have been referred to :
1. Broca, P. Des Anevrysmes. Paris, 1856.
2. Le Fort, L. Article "Anevrysme," Diet. Dechambre, V. iv., 1866.
3. Le Fort, L. Article " Sous-claviere," Diet. Dechambre, Troisieme serie, V. x., 1881
4. Poinsot, George. Article "Sous-claviere," Diet. Jaccoud, V. xxxiii., 1882.
5. Bergmann. Die Schussverletzungen und unterbindung der subclavia, St. Petersb
med. Woch., 1877. II. 99-200.
6. Bramann, (F.). "Das Arteriell-venose Aneurysma," Archiv f. klin. Chir., Bed.
1886, xxxiii. 1-107.
7. Souchon, E. Operative Treatment of Aneurisms of the Third Portion of the Sub
clavian Artery, .'\nnals of Surgery, vol. xxx., 1895.
8. Delbet, P. Traite de Chirurgie Clinique et operatoire. Le Dentu-Delbet, V. iv.
1897. (Maladies chirurgicales des arteres.)
9. Bergmann-Bruns-Mickulicz(Chirur. desHalses, etc.), Handbuchder Prakt.Chirurg
Bd. ii., 1900.
282
MATAS,
Tabulated Statement of Seventeen Eecoeded Cases of
Gathered from the
No.
Operator or
reporter.
Sex
and
age.
Nature
of in-
jury.
Seat of in-
jury.
Result.
Primary
hemor-
rhage
(syncope)
Second-
ary hem-
orrhage.
Associate
or compli-
cating
injury.
Date of
appear-
ance of
aneuris-
mal signs
1
2
Larrey, D. J.»
Paris.
Sanson.a
Paris.
M.
32
M.
50
Sabre
Gun-
shot
Left supra-
clavicular,
presumably
3d portion.
Left supra-
clavicular.
Recov-
eiy.
Recov-
ery.
" Fright-
ful hem-
orrhage,"
(syncope)
None.
None
recorded.
Brachial
plexus.
9
24 houTS.
" Next
day."
3
B6rard,3
Paris.
M.
adult
Stab
Right supra-
clavicular.
Recov-
ery.
" Not
very
Few days
copious."
4
Wattmann,*
Vienna.
M.
22 (?)
at in-
jury.
Gun-
shot
Upper arm
and shoulder
(subclavio-
axillary).
Died.
Post-ope-
rative
22 days
after
ligation.
31 years.
5
Wederstrandt,
J. P. C.8
New Orleans.
Smith. R.W.6
Dublin.
M.
adult
M.
m'dle
age
Gun-
shot
Stab
Right sub-
clavian, 2d
or 3d div.
Left supra-
clavicular
region (2d
division).
Recov-
ery.
Recov-
ery.
" Vio-
lent."
"Pro-
fuse."
None.
None.
Internal
jugular
vein in
addition to
subclavian;
brachial
plexus.
6
3 weeks.
7
Fisher, G.''
Giittingen
M.
32
Stab
Clavicular
region.
Recov-
ery.
None.
6th day.
8
Letenneur.s
Nantes.
M.
15
Gun-
shot
Right side of
neck, prob-
ably involv.
Istdivision
subclavian.
Recov-
ery.
Little.
None.
Suspected
brachial
plexus, jug.
vein close
to subclav.
junction.
Pleura
opened and
septic
haemo-
thorax.
Noticed
next day.
9
Will. J. C. 0.9
Glasgow.
M.
adult
Stab
Left subcla-
vian vessels,
3d division.
Died.
Profuse.
12th day.
13th "
19th "
20th "
12th day
tumor
found.
10
Kirsch, B.io
Breslau.
M.
27
Gun-
shot
Right supra-
clav. tumor
in delto-pec-
toral groove
near clavicle
(3d division).
Recov-
ery.
None.
Possibly
brachial
plexus in-
jured.
4th dav
1 Cliniques Chir., Paris, 1829, T. iii. p. 115.
2 Reported by Robert in These de Concours, Paris, 1842 (Des Auevrismcs de la region Susclaviculaire).
■s Bull, de Soc. de Chir. de Paris, 1S65, 2 v. 18G6, p. 367 et seq. Quoted by Richet in discussion of
Letenneur's case.
■> Abstracted from Bericht (iber die Deutsch Natur und aerzt. 21 meeting, 1843, Gratz, 1845. Also
reported by Rokitansky, Ueber die einige der wichtigsten kraukheiten der arterien, Wien, 1852.;
'" New Orleans Medical News and Hospital Gazette, 1854-55, vol. i. pp. 393-395.
TRAUMATIC A RT E K I 0-V EN O US ANEURISMS.
283
Arterio-venous Aneurisms of the Subclavian Vessels.
Literature (1827-1901).
Immediate {
effect of Non-opera- Operation, if any ; date
injury tive treat- and indication for
on arm. | ment. operation.
Distant or remote
effects of aneur-
ism on arm.
Arm icy, | Pressure,
pulseless, • ice,
colorless, repeated
venesect'n.
None.
None for
primary
injury.
No operation.
Atrophy, paralysis
of hand ; perma-
I nent obliteration
of pulse in all arm.
Remarks.
Double ligature third After lig. arrested
portion on 17th day pulsation in arm ;
foraggravationof pain , returned second
and vascular disturb- day ; infection ten
ances. j days after, and
secondary hemor-
rhage. .
None.
Enlarged
veins,
diminished
pulsation;
arrest of
circulation
on elevat'n
of arm.
; Notable
swelling of
arm. diffi-
cult deglu-
i titiou.
None re-
corded.
Boyer's
compressor
without
effect.
Rest, diet,
wet com-
presses
(arnica),
ice-bags.
Compresses Three weeks after injury
perchloride operation attempted,
of iron and but patient succumbed
glycerin, at first incision,
pressure,
opium,
ice, rest.
Instrumen- None,
tal com-
pression ;
not im-
proved.
Withered, paral-
yzed, cold ; no
sensation ; pulse
weaker and not
synchronous
with other side.
Arm cold, oedema-
tous, and pulseless;
sloughing of little
and ring fingers
and inner side of
dorsum and palm
to ulnocarpal
articulation.
Pain in shoulder
and elbow.
Persistence of aneurismal
signs for more than 10 years,
for which patient consulted
Sanson in 1832.
Discharged "several" weeks
later with persistence of
aneurismal signs, clamoring
for operation, which Bcrard
and Dietfenbach refused.
Immediate eflfects of primary
injury not recorded ; appar-
ently insignificant; aneur-
ismal signs and tumor re-
quiring ligature 31 yrs. after
primary injury: arterio-ven-
ous aneurism confirmed by
autopsy.
Died of diarrhoea, 1854, 7 yrs.
after injury, and with per-
sistent aneurismal symp-
toms ; arterio-venous aneur-
ism confirmed by autopsy.
About 7 mos. after injury
sloughing of hand occurred
spontaneously, slough de-
taching without constitu-
tional symptoms ; tumor at
site of wound size of walnut;
stationary.
Came under observation 1 yr.
after accident, with active
aneurismal signs, and was
discharged unimproved.
Wound healed and patient
took his first promenade on
21st day : after this no his-
tory can be obtained.
External wound had healed
already when first second-
ary hemorrhage occurred.
Autop.sy revealed arterio-
venous nature of injury.
Partial paralysis
fourth and fifth
fingers.
Came under observation 2^
months after injury and was
discharged unimproved in
any respect.
Arm paral-
yzed, anaes-
thesia of
fingers,
skin cya-
nosed.
8 Proceedings Pathological Society, Dublin, 1860-61, vol. i. part 3, p. 158.
^ In mittheilungen aus der chir. Klinik. Giittingen, 1861 (quoted in Bramann's table— Das
arteriell-veniise aneurysma). Archiv f. klin. Chirurg., Langenbeck, Berlin, 1886, vol. xxxiii. p. 12.
* Bull. Soc. de Chir. de Paris, 1865, second series, 1866, p. 867.
' Glasgow Medical Journal, Glasgow, 1875, vol. vii. p. 173.
1" Ueber traumat. aneurysm, Breslau, 1875. Thesis quoted by Bramann in " Das arteriell-venose
aneurysma." Archiv f. klin. Chirurg,, von Langenbeck, Berlin, 1886, vol. xxxiii. p. 12.
284
MATAS.
Tabulated Statement of Sevexteex Recorded Cases of
Gathered from the
Primary
Associate
Date of
Operator or
Sex
Nature
Seat of in-
hemor-
Second-
or compli-
appear-
ance of
No.
reporter.
and
of in-
jury.
Result rhage
ary hem-
cating
age.
jury.
(syncope)
orrhage.
injury.
aneuris-
mal signs
11
Arango,
A. P.,"
M.
27
Stab
Posterior
region of
Recov- " Abund-
ery. ant, con-
None.
8th day.
Medellin,
shoulder
trolled by
Spain.
(3d division).
patient's
hand."
12
Von Rotter,
M.
Stab ! Left infra-
Recov- Pouring
9 days
Nerve (not
Discov-
G.12
•2S
clavicular
ery. in a
after
deflnitelv
ered next
Berlin.
(3d division).
stream
(syncope)
injury
(mid-
night).
stated)."
day.
13
Wedekind.is
M.
Stab Left sub-
Recov- Profuse,
None.
None.
5 days.
(Jeorge,
32
clavian be-
ery. no syn-
Berlin.
low middle
of clavicle.
(3d division).
cope,
easily
control' d.
14
Veiel.i*
M.
Stab
Right infra-
Recov- Profuse.
3 days
None.
Noticed
Cannstadt.
23
clavicular
(3d division).
ery.
afte"r
injury
(mid-
night).
on 9th
day.
15
Matas, R.15
M.
Revol-
2d division
Recov-
Large
None.
Brachial
4 hours
New Orleans.
24
ver, 38 of subclavian
ery, hsema-
plexus ;
after in-
calibre through the
1 toma,
paralysis
jury.
ant. scalene.
external
hemor-
rhage
of arm.
1 moderate
no syn-
cope.
16
Vallas.i«
M.
Frac-
Supra-clav-
Death. Hsema-
None.
Internal
10th day
Lyons, 1900
25
ture of icular '2d and
toma
jugular
recog-
clavicle 1st division
formed
vein with
nized.
(indi- , (right side).
immedi-
subclavian
rect).
ately.
vessels.
17
Reboul,'-
M.
Frac-
Aneurisnial
Death.
Aneur-
None.
Tubercu-
8th day
Montpellier,
30
ture of ' hsematoma
ismal
losis of
after in-
France, 1891
left enormous,
tumor
lungs and
jury :
clavicle filling supra-
; probably
of iierito-
aneurism
(indi- clavicular
I began
neum ;
p'sitively
rect). region and
9 days
marked
develop'd
whole left
after in-
cachexia
35 days
side of
jury.
and maras-
after
•
|hack & chest.
mus.
injury.
1' Bull, et M(5m. Soc. de Chir.. Paris, 1880, vol. vi. pp. 60 and 70, and An. de I'Acad. de Med. de
Medellin. Medellin, Spain, 1892 xv. pp. 55-57. Abstracted from Spanish text, 1892.
'- Ueber die Stichverletzungen der Schlusselbeingefass, Berlin, klin. Wochenschrift, 1893, vol.
XXX. pp. 278-284.
13 Deutsch med. Wochen., Leipzig, 1895, vol. vii. p. 53.
TRAUMATIC A RT E R I 0-V ENO US ANEURISMS.
285
Arterio-venous Aneurisms of the Subclavian Vessels.
Literature (1827-1901).
Immediate i
effect of Non-opera- Operation, if any ; date Distant or remote
injury live treat- 1 and indications for effects of aneur-
on arm. ment. i operation. ism on arm.
Remarks.
Swollen,
Compres-
cold.
sion; band-
purple,
ages to
pulseless,
arm.
medius.
ring, and
I'tle fingers
paralyzed.
Pulse weak
Wound
and
packed
retarded.
with
cyanosis,
iodoform
enlarged
gauze.
veins, etc.
Pulse
Antiseptic
weaker.
dressings
to wound.
After
Antiseptic
injury
dressings.
radial
pulse
retained.
None.
On 9th day (midnight)
clavicle resected; artery
ligated on outer side of
scalenus, subclavian
and other veins ligated;
wound allowed to heal
by granulation.
No operation.
Q2dema of arm ; JTen years after operation pa-
varicose veins of i tient was reported by friends
arm. in almost perfect health.
Arm cold and
pulseless during
operation ; pulse
did not return.
Arm feels numb ;
tingles when
allowed to hang.
Pulse lost Gauze com-
immedi- press and
ately, re- i adhesive
turned 5th | plaster,
day. ice-bags.
Arm
motionless
from
fracture.
On 9th day artery ligated
outside of scalenus; ax-
illary artery ligated be-
yond wound ; both ax-
illary veins tied and
venous branch from
scapula ligated ; clot
turned out of sac and
wound packed
On 9th day. Sept. 13, 1900,
subclavian ligated on
both sides of scalene ;
lateral suture of vein ;
osteoplastic resection
of clavicle, provisional
traction loop around
anomalous subclavian
first portion ; wound
healed per primam.
Operation for suppura-
tion in sac, Sept. 22, 1900;|
resection of clavicle ;j
prophylactic ligature ofi
subclavian artery impos-
sible; free incision into
sac; frightful hemor-;
rhage controlled by 7!
forcejjs left in sUu ; !
wound packed. '
Bandage No operation attempted,
for patient too weak,
fracture,
Immediately after
operat'n arm white
and cold ; veins
thrombosed, arm
blue and hand
swollen; sensibility
impaired ; thermic
sense lost ; arm
diminished in size.
Sloughing of
thumb and little
finger, part of
hand and forearm.
Gelatin
injection,
immobil-
ization
bandage.
Discharged a few weeks after
operation healed ; resumed
occupation as a stone-cutter;
no gangrene or disability of
extremity reported.
7 mos. after injury all signs of
aneurism persist, but suffers
no inconvenience, and fol-
lows regular occupation
(locksmith).
Last report ^3^ mos. after in-
jury ; marked disability of
arm and hand ; trophic and
vascular changes marked.
Last report July 1, 1901 ; pa-
tient in robusthealth ; right
hand and forearm perma-
nently disabled.
Death four hours after opera-
tion from surgical anaemia
and shock. Autopsy : non-
union of fracture; internal
jugular and subclavian
veins torn by distal frag-
ment, subclavian artery per-
forated also; scalenus anti-
cus torn from attachments.
Death five days after admis-
sion to hospital while en
route to his home; aneur-
ismal ha'raatoma enormous,
filled entire supraclavicu-
lar space front of chest and
back, displacing scapula.
'< Medicinische Correspondenz-blatt des Wurtemburg aerzte landsverein, Stuttgart, 1895, vol.
xlv. p. 123.
'■' Transactions OF THR American Surgical Association, 1901.
'« Reported by Galiois and PioUet, Rev de Chirurg., Paris, .July 10, 1001, No. 7, pp. 2;i-30.
1" Reported by T. Fabre. Thesis, Montpellier, 1894 ; and Galiois and Piollet, Rev. de Chirurg.
July 10, 1901.
286 MATAS,
APPENDIX.
Two Additional Cases of Traumatic Arterio-Venous
Aneurisms of the Subclavian Vessels, and One
of Injury of Both Vessels, Not Included
IN the Text.
Case I. Arterio-venous afieurism of the right subclavian artery and
of the subclavian and internal jugtdar veins, caused by indirect fracture
of the clavicle ; operation; death. — Operator, Dr. Vallas, Hotel Dieu,
Lyons. Reported by MM. Gallois and Piollet, Revue de Chirurgie,
Paris, July lo, 1901 : 2ime Annee, pp. 23-30.
A. F., aged twenty-five years ; farmer; good antecedent history, but
weak constitution; small stature and spare build; habitually pale.
On July 2, 1900, while riding a mule the patient was suddenly thrown
to the ground. He first fell on his feet, and then on his right
shoulder. He felt an acute pain in the shoulder, but picked himself
up and led the mule back to his stable. In doing this he had to walk
up an inclined road by a hillside for twenty minutes. While on his
way home he became conscious of the formation of a large swelling
at the root of the neck on the right side. This swelling increased
rapidly, and by the time he reached his house it had reached the ear
and projected beyond it. As he walked he became short-winded, and
when he arrived at the house he was completely exhausted. He could
not stand on his feet, and had to go to bed at once. A physician
who was summoned detected a fracture of the clavicle, with consider-
able subcutaneous emphysema. In the days that followed the swell-
ing rapidly diminished, while a very considerable ecchymosis spread
from the neck to the corresponding side of the chest.
When on the tenth day the bandages were removed a persistent but
almost painless tumor had formed immediately above the clavicle and
outside of the sternomastoid muscle. As this tumor remained the
patient consulted other physicians at Grasse, who diagnosed an aneu-
rism of the subclavian artery, caused by fracture of the clavicle. On
September 9th (about sixty-two days after the accident) a gelatin
serum injection, prepared by Lancereaux's method, was administered.
TRAUMATIC A RT ER I 0-VEN O US ANEURISMS. 28/
The patient was then advised to enter Professor OUier's clinic at
the Hotel Dieu, Lyons, where he was admitted Septennber 19th.
Condition on admission : The supraclavicular fossa is filled with a
mass as large as a fist, which extends from the outer edge of the
clavicular attachment of the sternomastoid to the outer third of the
clavicle. The tumor is globular in shape, but irregular in contour.
The upper outline of the tumor can be felt four fingers' breadth above
the clavicle. It is most prominent about the level of the fracture,
which is situated at the junction of the outer with the middle third of this
bone. There is a complete failure of osseous union ; the fragments are
movable. The inner fragment projects under the skin anteriorly. The
outer or acromial fragment is driven inward and backward, but appears
to be outside the anterior scalene. The patient can scarcely move his
arm, which hangs motionless by his chest. All the signs of aneurism
are recognizable in the tumor, except that there is no thrill. There is
a distinct systolic murmur and expansile pulsation. Pulse, 100, can
be distinctly felt at both wrists, though weakeron the right side. The
right carotid can he outlined along the inner side of the sterno-
mastoid. No pleural or pulmonary lesions. No apparent lesion of
brachial plexus. A swelling still remains at the seat of the gelatin
injection. On September 20th the patient complains of pain in the
aneurism. He has fever. Temperature, 38.8 C. ; pulse, 108. The
swelling, indicating seat of gelatin injection, is also tender and
inflamed.
On September 21st the tumor increases rapidly in size; the over-
lying skin is red, oedematous, and inflamed. The seat of gelatin
injection is also evidently inflamed and infected.
In the absence of Professor Oilier, Mr. Vallas takes charge of the
case and diagnosticates "an inflamed aneurismal haematoma, with
threatened suppuration of the sac and general septic infection." It
is decided that an operation is urgently indicated, and Mr. Vallas
operates September 2 2d, 1900. Ether anaesthesia. A horizontal in-
cision is made parallel with and one finger's breadth above the clav-
icle ; this is joined by a vertical incision following the inner edge of the
sternomastoid down to the sternum. The insertion of the sterno-
mastoid is divided and reflected upward together with the cutaneous
flap. The omohyoid is divided in the middle, and each end is re-
tracted. The sac is now exposed. In order to expose the subclavian,
which is hidden by the tumor, the whole inner fragment from the line
of fracture to the sternoclavicular joint is disarticulated and excised.
288 MAT AS,
Notwithstanding the great exposure of the field obtained by this
procedure, it is still difficult to recognize and isolate the subclavian
artery. The trunk of this vessel is hidden by the sac and the large
trunk of the right innominate vein. At this juncture, while explor-
ing for the artery with a grooved director, a discharge of about a
tablespoonful of thick, reddish pus takes place, and the director pene-
trates into the cavity of the sac. At the same time a large clot appears
and obliterates the opening made in the sac. In view of the difficulty
of applying a prophylactic ligature upon the subclavian artery at its
origin, M. Vallas decided to make a large free opening into the sac,
with the view of securing the injured and bleeding vessels in situ.
The instant this is done a flood of mixed blood and clots deluges the
field, the hemorrhage coming simultaneously from many points. In
spite of a vigorous tamponade of the sac, the blood continues to
flow. It appears to come most vigorously from the upper and inner
angle of the wound. The cutaneous incision is quickly enlarged, and
while the assistants are making vigorous compression at the bottom of
the sac, the operator succeeds with much difficulty in placing two
forceps on the internal jugular, one within and the other outside the
sac. This stops the bleeding at this point. On removing the gauze
packs the hemorrhage instantly recurs, pouring from several orifices.
After great difficulties and much loss of blood, the bleeding is finally
controlled by a series of forceps applied to the chief bleeding-points.
In the meantime the patient grows very weak, and 500 grammes of
saline solution are injected and other restoratives are applied. The
wound is packed with iodoform gauze, leaving seven clamps in situ.
The patient is then put to bed, but in spite of the additional injection
of 500 grammes of saline solution death takes place four hours after the
operation.
Autopsy. A very oblique fracture of the clavicle is recognized, the
sharp edge of the outer fragment projecting four centimetres beyond the
line of fracture. The scalenus anticus is almost completely torn from
its attachment to the first rib. The internal jugular vein is opened
longitudinally by a tear two centimetres in length. The subclavian
vein had been almost completely torn across, and its walls were incor-
porated in the sac.
The subclavian artery showed a small perforation which communi-
cated with the sac. The tear in the artery had taken place a short dis-
tance from the thyroid axis. The internal jugular was also opened
and freely communicated with the sac. The distal fragment had,
TRAUMATIC A RTE K I 0-V ENO US ANEURISMS. 289
therefore, been driven into the neck, tearing the scalenus anticus and
penetrating the subclavian and internal jugular veins and the middle
third of the subclavian artery.
Case II. Arierio-venous aneurism (^probably of the subclavian artery
and veiii) caused by indirect fracture of the clavicle ; no operation ;
death. — Service of D. Reboul, Montpellier, France. Originally re-
ported by Th. Fabre. These, Montpellier, 1894, and abstracted from
Gallois and PioUet's article, loc. q\\.., Revue de Chirurgie, No. 7, July
10, 1901.
J. A., aged thirty years ; locksmith. Fell from a carriage March
4, 1894, and struck left shoulder. The clavicle was fractured at the
junction of the outer and middle third. The fracture was set with
immobilizing bandages. Eight days after the accident the patient
removed the bandages and tried to use his arm. While moving the
arm he felt a sharp pain at the seat of fracture, which radiated to the
dorsal surface of the forearm and hand. On March 31st (nineteen
days after this occurrence) another sharp pain was felt by the patient,
and a tumor was felt in the supraclavicular space on a level with the
fracture. On April 8th the patient was seized with a violent cough,
and the swelling greatly increased in size, and became most painful.
A traumatic aneurism was then recognized by the attending physician.
On April loth he was seen by Dr. Reboul, who confirmed the diag-
nosis. All the signs of aneurism existed, including a marked thrill
and signs of venous disturbance. The tumor extends over the left
thoracic region and covers an immense area. It extends five centi-
metres below the nipple, fills the axilla, and descends to the ninth
rib; it projects posteriorly in the dorsal region, where it lifts the
scapula and displaces it outward, and can be felt transversely, touch-
ing the vertebral column downward to the tenth rib. The entire
supraclavicular space is filled by it, the penetrating hsematoma, up to
the posterior border of the scalenus. The veins are turgid and ob-
structed. The left arm is powerless. Marked trophic disturbances
exist in the arm, showing lesion of the brachial plexus. The pulse
in the left brachial and radial arteries is scarcely perceptible. In
addition to this great vascular disturbance, the patient gives evidence
of advanced pulmonary tuberculosis and of chronic peritonitis. In
view of all these complicating and hopeless conditions, and the very
bad state of the patient, which would not even justify the administra-
tion of an ancesthetic, Dr. Reboul decides not to interfere. Five
days after his admission to the hospital the relatives of the patient
Am Surg ig
290 MATAS,
decided to take him to his village. He died en route, and no post-
mortem was held.
Note. — Gallois and Piollet, after a careful consideration of this
case, believe that it should be classified as an arterio-venous aneurism,
as all the signs pointed to a lesion of both artery and vein.
[In Gallois and Piollet's very interesting contribution, ten obser-
vations are summarized from the literature, which illustrate the dan-
gers of closed (simple) fractures of the clavicle from the stand-point of
complicating lesions of the subclavian vessels. In only two of these
ten cases were both vessels (artery and vein) implicated, and these are
so rare and instructive that they are worthy of special and full men-
tion in connection with the subject of this paper, — R. M.]
Case III. Vasilyeff (M. A.) Subclavian artery and vein tied
under the clavicle for hemorrhage in abscess cavity. — Chir. Vestnik,
1886, II. 431-436. (Surgical Clinic of Prof. J. A. Yefremowski.)
M. L., female, aged twenty years, entered clinic November 21, 18S4.
Patient first felt pain caused by an abscess (?) two weeks previously.
Tumor was found in right axilla, which increased until the 29th, when
it occupied the subclavian and axillary regions. December ist, under
chloroform; incision made by Vasilyeff in axillary line, much pus
issued ; finger inserted in abcess cavity ascended to middle of clavicle ;
wound enlarged and drainage inserted ; great hemorrhage occurred,
stopped by grasping bleeding-points en masse with haemostatic forceps
and left in place. December 3d, dressing changed. Much bleeding
at night. December 4th, pulse, 104; temperature, 38.6° C. Profes-
sor Yefremowski, under chloroform, enlarged wound, sought cause of
hemorrhage ; on removal of forceps, hemorrhage great and subclavian
artery was then tied ; hemorrhage stopped a while, then began again,
and was venous ; subclavian vein was then tied. Wound was disin-
fected, packed and bandaged ; patient put to bed ; hot bottles around
arm. Profuse sweating at night. Pulse in left hand, 100 ; tempera-
ture, 39.3° C. December 6th to 20th, daily change of dressing.
Temperature varied, 38^^ C. morning to 39° C. night and more.
Pulse in radial artery of operated arm not found ; oedema of arm in
spite of flannel bandage with pressure. December 14th ligature slipped
from artery. Small abscesses in little finger and palm \ opened and
changed on alternate days ; wound healed by granulation ; oedema ;
tumor in region of external middle of humerus ; acute osteomyelitis of
TRAUMATIC A R TER I O-VEN O US ANEURISMS. 29 1
humerus ; two counter openings made and drains inserted intero-
externally. March ist, erysipelas in the arm and chest ; wound
healed the middle of the month. Wound healed; function of arm
limited ; right arm thinner than the left. Movement in shoulder and
elbow-joints impossible. Massage, active and passive movements.
Electricity.
June i6th. Left hospital. Movement in the shoulder-joint ; almost
re-established in elbow; in phalangeal, metacarpal joints, flexor move-
ments imperfect ; no pulse in right radial artery.
Patient was seen in fall of 1885 ; improvement; does hard work;
no radial pulse, but right arm thinner than left.
[Note. — This case is properly not one of arterio- venous aneurism of
the subclavian vessels, but simply illustrates the dangers of hemorrhage
and infection following a secondary ulceration of these vessels when
exposed in a suppurating cavity. As this observation, originally pub-
lished in a Russian journal, is difficult of access, it is here reproduced
for the benefit of other students of the literature of the subject who
may be interested in the nature of the case in consulting the bibli-
ography.— R. M.]
292 DISCUSSION,
DISCUSSION.
Dr. Arthur Dean Bevan, of Chicago.
I am sorry that the duties of the Nominating Committee have pre-
vented me from hearing the paper of Dr. Matas, but he sent me a
synopsis, and I have a very brief discussion to present after reading it.
The case reported by Dr. Matas represents such a rare condition, the
histories of the few similar cases have been so thoroughly reviewed,
and the surgical procedures adopted by him have been so well planned,
that there is little room for criticism. I have not handled a similar
case, but have studied this field somewhat in a case of traumatic aneu-
rism of the carotid, as well as in one other case. The point which
presented itself to my mind, and which would naturally present itself
to the mind of a surgeon confronted with such a case, in addition to
the facts brought out by Dr. Matas, was the possibility of suturing
both the artery and vein after temporary ligation of the vessels. My
present view would be in favor of Dr. Matas' plan of applying a suture
to the vein and relying upon a ligature for the artery. One must also
remember the possibility of effecting a cure by proximal and distal
ligation of the artery close to the point of injury without ligating the
vein, and this is a question which should be carefully considered. The
great desirability is to include as small a part of the artery as possible
between the ligatures. The fear of secondary hemorrhage has largely
disappeared, and it has been clinically shown that, provided primary
healing is obtained, there is little ground for the return of this fear, as
is shown in ligating the external carotid. In regard to hemorrhage
from the vertebral artery, this is to be expected when the subclavian is
ligated proximal to that branch, and again in its third portion ; of
course, a hemorrhage from the vertebral would necessarily take place
in all cases. As to the prognosis without operative interference, this
is a very interesting point in connection with these cases, as the prog-
nosis is surprisingly good without interference, and the life-history of
these cases has been longer without interference than with it. Liga-
ture of an arterio-venous aneurism of the carotid gives a life- history
of from twelve to twenty years, whereas it is longer in the non-oper-
ated than in the operated, thus making the question of operation., as
has recently been stated, rather a relative one.
The question of the use of gelatin in these cases is to be consid-
TRAUMATIC ARTERIO -VENOUS ANEURISMS. 293
ered. Recently a colleague of mine has had a case under observa-
tion which he presented to the Chicago Surgical Society, in which he
believes he has obtained a distinct improvement by 2 per cent, gelatin
injections. Of course, one should mention the treatment by digital
compression.
One thing interested me particularly from the stand-point of the sur-
gical anatomy, and that is the singular fact that the last two cases of
ligation of the subclavian vein reported in the literature on ligation
the operators have made the statement that they were cases of anoma-
lous subclavian artery. They were both on the right side, and sprung
directly from the arch. On cannot help but be struck with this fact,
and to ask for an interpretation. Personally, without criticising the
observations of either of these operators, I should be rather inclined
to the view that probably in both cases the operators were surprised at
the great length of the artery. Post-mortems would possibly have
demonstrated a short innominate. That would be one's natural con-
clusion from the rather great rarity of this anomalous subclavian coming
direct from the arch.
Dr. W. S. Halsted, of Baltimore.
I really have nothing to say except to congratulate Dr. Matas upon
this operation, as I know what it means and what a great deal of nerve
it takes. My case was on the left side, and I ligated the first portion
of the subclavian.
In reference to the cocaine solution, I agree with Dr. Matas that the
principles which Schleich has emphasized, and which I emphasized
before him, are very important ones. I wish to say a word in refer-
ence to the use of very weak solutions. For many years we used solu-
tions that had scarcely any cocaine in them. We began with a very
weak solution, and continued with water, while in some cases we used
water alone. We foimd that very mild solutions of cocaine were better
than water, and discovered that a i : 3000 or i : 5000 worked satisfac-
torily in every case. For ordinary purposes this is sufficient, and
patients do better when very little cocaine is used. Their power of
resistance is greater, and later they lose their inhibition, which is one
reason for using mild solutions. I recall the case of an old gentleman
from out of town who was suffering from two hernias where cocaine
was used in the operation. A i : 1000 solution was employed for the
first operation, and he was very much affected by the cocaine, although
very little was used. For the first twenty-four hours he was very much
294 DISCUSSION.
depressed, and said he would not have the other side done. We
finally persuaded him to let us do it, which we did with a very mild
solution indeed. He had no bad effects, and stood the operation very
much better.
My first publication on water as an anaesthetic is, of course, remem-
bered, and in the two articles I wrote later all the points made by
Schleich were discussed.
Dr. Theodore A. McGraw, of Detroit.
There is one other point which is very important upon which I would
like to say a word. The prognosis of all traumatic aneurisms is a very
different thing from the prognosis of aneurisms due to divided artery.
After the Civil War I examined for pensions for many years, and saw
a large number of old soldiers with aneurisms. I remember one man
who had an aneurism of the carotid artery produced by a gunshot
wound. Year after year he came to me to be examined, and I saw
him for a number of years in succession. Another man had a blow
in the femoral artery, which lasted twenty years, with traumatic aneu-
rism. In these large arteries of the neck, where operations are ex-
ceedingly dangerous, this point should be taken into account.
Dr. Bevan. In regard to the Dr. Halsted whom I mentioned in
my discussion, I would like to state that I referred to the Dr. Halsted
in Chicago as the man who had recently ligated the first portion of
the subclavian.
Dr. Matas. The points presented by Dr. Bevan and the gentlemen
who have followed him are very well taken. They have struck the
keynote of the discussion when referring to the prognosis. I have
fully discussed this plan of the subject in my paper, but the limited
time at my disposal prevented me from referring to it in the abstract.
After the arterio-venous anastomosis has been fully established, the
question. Shall we operate or not? is a very serious one. In ii or 12
cases out of 15 the patient recovered from the immediate effects of the
injury without operation, but many observations fail to show what
became of the patients in after years. In several of these the subse-
quent history shows that the lesion persisted with evil and disastrous
consequences ; in others there was a well-authenticated survival after
a long interval of time ; but in all but two of the unoperated cases
the lesion persisted in an active state indefinitely in spite of the treat-
TRAUMATIC A RT E R I 0-V ENO US ANEURISMS. 295
ment ; in several it is apparent that the lesion was simply tolerated
because there was no other alternative left to the patient. In the
majority of the cases it cannot be denied that the lesion persists as an
active pathological condition, which, while compatible with a long
survival, is always a menace to the health and life of the patient. It
creates a weak and vulnerable point in the circulation. The interest-
ing question that is not yet decided is, Have the conditions of opera-
tive surgery progressed sufficiently to justify a departure from the old-
established rule of non-interference .to a more aggressive policy?
This question I have endeavored to answer in my paper. In my own
case I departed, against my inclinations, from the old classical rule of
non-intervention, chiefly because the lesion was a very recent one and
the patient could not remain in the city under observation, and I felt
that he could not be trusted in his doubtful condition in a distant set-
tlement without risk.
While I am much gratified at the result, in spite of the unfortunate
sloughing of a part of the extremity (which had been previously par-
alyzed by the injury) the case fully illustrates the difficulties and dangers
of a radical operation, and convinces me that in spite of the improved
technique of the day it is still wise to follow the old rule of absten-
tion in all cases in which the danger of secondary hemorrhage is past
and the arterio-venous anastomosis is well tolerated. While accepting
this conservative attitude as the proper one in old-established cases, I
do believe that the indications for interference and radical operation
have broadened, and that the surgeon is thoroughly justified in oper-
ating in all favorable cases whenever the lesion causes disturbance and
threatens complications.
AN OPERATION FOR THE RADICAL CURE OF
UMBILICAL HERNIA.
By WILLIAM J. MAYO, A.M., M.D.
ROCHESTER, MINN.
The results of operation for the radical cure of umbilical
hernia in adults have not been encouraging. These patients
are usually obese, with attenuated abdominal muscles, and the
thin, rigid character of the ring does not offer mechanical con-
ditions advantageous to lasting union.
The principles of closure have been the same as after an ordi-
nary abdominal section, the object being to split the fascia at
the ring margins laterally, until the recti muscles are reached,
and then by a series of buried sutures to reconstruct the abdom-
inal wall in layers. The defect in this method is the natural
separation of the recti muscles at the level of the umbilicus.
Below this point the muscular structures are practically in con-
tact, but above there is normally from one-fourth to three-fourths
of an inch separation. To bring the recti together in this
locality amounts to a muscle transplantation. In small hernias
this muscular approximation is not difficult, but in the larger
openings an inch or more in diameter it is impracticable, and so
far as I have been able to judge the attenuated muscles, when
secured, are not of great value as retentive agents in this variety
of hernia. In very corpulent subjects the muscular separation
is greater. If such a patient, lying on the back, be directed to
rise, bringing into play the recti muscles, the lateral deviation
at the level of the umbilicus is easily shown, and, in the majority
of cases, demonstrates the impossibility of bringing them firmly
into median apposition.
Fig. I.
Showing exposure of hernia and lateral incisions.
RADICAL CURE OF UMBILICAL HERNIA. 297
Lucus Chanipionnicre, after making a plea for operation in
the acquired umbilical hernia of adults, well says that, although
the operation frequently fails, the relapse is less uncomfortable
to the patient and has less danger of strangulation than the
original hernia. This is especially true of relapses after division
of the umbilical ring; the return partakes more of the nature of
a ventral hernia, the internal opening being nearly, if not quite,
the diameter of the protrusion. The late Grieg Smith' directed
that the incision should be made over the thinnest part of the
umbilical sac, and this advice seems to have been generally
adopted.
Ransohofif,- in a practical paper, calls attention to the loss of
time in dissecting down through one of these protrusions filled
with adherent viscera, in danger constantly of wounding im-
portant structures, and lays down the principle that the incision
should always be made into the free abdominal cavity at the
neck of the hernia. This at once allows an inspection of its
contents and return of intestinal coils, if present. The adherent
omentum can be ligated at the internal opening, saving both
time and trouble. In strangulated conditions, as pointed out
by Barton, the knuckle of pinched intestine is usually in the
centre of the adherent omentum, and with this form of incision
the operator is in no danger of injuring the bowel. Ransohoff
used silver wire in his reported cases as permanent sutures, and
we have followed the same plan. Silver wire buried in bone
and aponeurosis seldom gives trouble, because it lies in fixed
tissues, although in movable structures like muscle, atrophy
necrosis may occur and necessitate its removal. Wheaton^ ad-
vocates operation in the larger varieties of umbilical hernia on
account of the extreme disability which it causes, and in this
class of cases brings up the question as to the return of the
contents of large hernias, especially when they have been irre-
ducible for more than two years. In this time, he says, ''The
extruded viscera has lost the right of habitation," and recom-
mends that before operation the patient be kept in bed for
' Annals of Surgery, 1895. ''' Medical Record, 1897.
3 St. Paul Medical Journal, December, 1900.
298 MAYO,
several weeks, and means taken to reduce the body-weight. We
have followed this method, and after removal of sufficient omen-
tum have seldom had trouble in returning the hernial contents.
In a paper read before the American Academy of Railway
Surgeons on October 4, 1898, and published in the Annals of
Surgery for January, 1899, I called attention to the imprac-
ticability of covering in the defect left by excision of the larger
umbilical hernia with muscle, and advocated the overlapping
of the aponeurotic structures which were already at hand,
securing a wide area of adhesions in place of edge-to-edge
union. This method we had then employed in five cases, in
three the overlapping was from side to side, and in two from
above down. Extensive lateral incisions to find sufficient
muscle to make the routine operation described by surgical
writers compelled us as a matter of necessity to overlap from
above downward, and to our satisfaction we found the parts
came together with less tension than when drawn laterally, and
time proved that the strength of the union was as lasting.
The first of these overlapping operations was done in 1895.
We have now made this operation nineteen times, ten times
overlapping from side to side and nine times from above down-
ward. The larger openings have usually been more easily
closed by the latter method. The principle employed is not
unlike the Championniere operation for the radical cure of
inguinal hernia. In Championniere's method the external
oblique is overlapped in a similar manner to the operation
described, and his results in 800 cases have not been excelled.
The method of radical cure of inguinal hernia suggested by
E. W. Andrews also depends upon the overlapping of the fascia
of the external oblique for its success.
The umbilical operation is performed as follows :
1. Transverse elliptical incisions are made surrounding the
umbilicus and hernia ; this is deepened to the base of the hernial
protrusion.
2. The surface of the aponeurotic structures are carefully
cleared an inch and a half in all directions from the neck of
the sac.
RADICAL CURE OF UMBILICAL HERNIA. 299
3. The fibrous and peritoneal coverings of the hernia are
divided in a circular manner at the neck, exposing its contents.
If intestinal viscera are present the adhesions are separated and
restitution made. The contained omentum is ligated and re-
moved with the entire sac of the hernia.
4. With forceps the margins of the ring are grasped and
approximated ; whichever way the overlapping is more easy of
accomplishment suggests the direction of closure. The figures
show the overlapping as done from above downward.
5. For this approximation an incision is made through the
aponeurotic and peritoneal structures of the ring, extending one
inch or more transversely to each side, and the peritoneum is
separated from the under surface of the upper of the two flaps
thus formed.
6. Beginning one inch or more above the margin of the upper
flap, three to four silver wire mattress sutures are introduced, the
loop firmly grasping the upper margin of the lower flap, suf-
ficient traction is made on these sutures to enable peritoneal
approximation with running suture of catgut. The mattress
sutures are then drawn into position, sliding the entire lower
flap into the pocket previously formed between the aponeurosis
and the peritoneum above.
7. The free margin of the upper flap is fixed by catgut sutures
to the surface of the aponeurosis below, and the superficial
incision closed in the usual manner. The lateral approxima-
tion is carried out by sliding one side under the other in the
same manner. In the larger hernise the incision through the
fibrous coverings of the sac may be made somewhat above the
base, thereby increasing the amount of tissue to be used in the
overlapping process. In only one case were we unable to satis-
factorily close the opening, as described, on account of the large
size of the umbilical ring. In this case less than one-half an
inch of overlapping was secured, and that under great tension,
The result was a boat-shaped stretching of the united parts, but
the symptomatic cure was excellent. The results in the other
cases, so far as known, have been good, although many of them
are too recent to be called cured, and possibly relapses will occur.
3C0 MAYO,
Piccoli^ reports a case successfully operated upon in August,
1899, after a similar plan, and refers to a case reported by
Bonomo operated upon December 9, 1899, with a favorable
result. J. A. Blake^ reports several cases operated upon by the
same method during 1900, and refers to an article by Sapiejko/
in which an identical operation is described. It is evident that
a number of operators have independently worked out the same
idea. All reported favorable results.
1 Centralblatt. f. klin. Chir., Jan. 13, 1900.
2 Medical Association of Greater New York, January 14, 1901.
3 Rev. de Chir., 1900, No. 2, p. 240.
RADICAL CURE OF UMBILICAL HERNIA. 3OI
DISCUSSION.
Dr. A. J. OcHSNER, of Chicago.
There are four methods of treatment of umbilical hernia in the
adult which seem worthy of consideration :
1. The method consisting in the excision of the umbilical ring and
the closure of the defect by several rows of sutures as recommended
by Quenu, Gersuny, Ransohoff, Championniere and others. In this
method five layers are sutured separately : i. Peritoneum and trans-
versalis fascia. 2. Posterior fascia of rectus abdominis muscle. 3. The
rectus abdominis muscle on each side to its fellow. 4. The anterior
fascia of the rectus abdominis muscle. 5. The skin and superficial
fascia. Some authors insert tension sutures, passing through all of
these layers down to the first one mentioned, which are left until all
of the layers have been sutured separately and then tied for the pur-
pose of relieving the tension upon the sutures applied to the various
layers. Others depend entirely upon the sutures applied to the dif-
ferent layers. Various suture materials are used by the different authors,
from ordinary catgut to metallic sutures.
2. Various methods involving splitting, crossing, or transplanting
portions of the recti muscles have been recommended, especially by
Dauriac in France and Scatolari in Italy.
3. The implantation of aseptic sponge or gold or silver wire net-
work has been praised by Witzel, Phelps and others. This method
has not been tried for a sufficient time to enable one to judge of its
value.
4. The method first described by Dr. Mayo several years ago, as
brought forth in the paper under discussion.
The first method described I have used in a number of cases with
satisfactory results only when the separation between the recti muscles
has not been great, and when the latter structures had not atrophied
to too great an extent. This condition, however, is exceedingly
common in very obese patients. About three years ago Dr. Mayo
showed me his method, and since then I have employed it in seven
cases. In these cases I have used chrome-catgut sutures.
Case I. — January 26, 1899, I operated upon Mrs. A. B., aged
thirty-one years, suffering from an umbilical hernia the size of an
orange. I made the typical operation, and she left the hospital in five
weeks perfectly well. She has had no recurrence.
302 DISCUSSION.
Case II. — On July ii, 1899, Mrs. W., a woman, aged fifty-eight
years, weighing over 300 pounds, who had suffered from an umbilical
hernia the size of a hen's egg for a number of years. It had become
violently strangulated twelve hours before I saw her. When first seen
by me the skin covering the hernia was black and very thin, so that
the dark-colored omentum could be seen through it. I opened the
sac, replaced a portion of the transverse colon which had been strangu-
lated, and removed the sac. The ring was an inch in diameter, but
the piece of transverse colon had been forced into the sac and held
there by the pedicle of a mass of omentum which had evidently been
adherent for a long time to the neck of the sac. The discolored
omentum was ligated and removed and the stump replaced. Then
the opening was closed transversely by Mayo's method. The patient
recovered and has had no recurrence.
Case III. — December 10, 1899, I operated upon Mrs. M. R., aged
fifty years. The patient was suffering from a painful umbilical hernia
as large as a hen's egg. The same operation was performed, with the
same result. She remained in the hospital four weeks.
Case IV. — Mrs. O. J., aged fifty-four years, also a very obese patient,
came to me for treatment of umbilical hernia October 8, 1900. I
placed her on a restricted diet and advised walking long distances.
On December 7, 1900, she returned with her weight reduced thirty
pounds. The hernia was as large as a fist, and contained adherent
omentum. The adhesions were loosened and the omentum replaced
and the opening closed transversely by Mayo's method. She left the
hospital four weeks after the operation with her weight still further
reduced twenty pounds.
Case V. — Dr. G. E. M , a very obese patient, who had acquired a
very painful umbilical hernia, the size of a hen's egg, in a runaway
accident five years ago, came to me February 17, 1901. The hernia
contained adherent omentum. I performed Mayo's operation, and
he went home well, three weeks after the operation. In a letter just
received he states that his abdominal wall is strong, and that he is as
well as before his accident.
Case VI. — Mrs. H. W., a very obese woman, aged forty-two years,
came to the hospital February 18, 1901, suffering from a painful um-
bilical hernia the size of half an egg. I performed the same opera-
tion, and she left the hospital well four weeks after the operation.
Case VII. — An obese woman, aged sixty-seven years. I have just
operated, April 26, 1901.
RADICAL CURE OF UMBILICAL HERNIA.
303
Of course, the time in all of these cases is too short to justify any
conclusions, but I have been impressed with the value of this opera-
tion as compared with the others. I believe that every surgeon who
has once tried this operation will be convinced of its value. After
the operation has been completed vomiting or straining does not seem
to make any impression upon the repaired portion of the abdominal
wall, and in all of my cases the patient has felt perfectly secure ever
after the operation. I have been in the habit of supporting the
abdomen with broad rubber adhesive plaster strips for two months
after the operation. These patients have also all been advised to sub-
ject themselves to a moderate diet and to walk a great deal to increase
their muscles and to decrease their fat.
In looking over the literature of the subject I have encountered an
304 DISCUSSION.
article by Dr. E. Piccoli, an Italian surgeon (^Centralblait f. Chir.,
January 13, 1900), in which exactly this same operation is described,
as is shown by the accompanying illustration. The author had per-
formed this operation once, on August 29, 1899, which was long after
it had been described and practised by Dr. Mayo, and eight months
after my first operation. He states in his article that Dr. Bonomo
reported at the Congress of Italian Surgeons in Rome on December
9, 1899, that he had also invented and practised a method which is in
all essential respects identical with Dr. Piccoli's and, as we see also,
with Dr. Mayo's method.
The method has so much to recommend it that it is not at all sur-
prising that it should have been invented independently by at least
three different surgeons. Of these Dr. Mayo was undoubtedly first
by several years in point of time, although, of course, this fact is of
very little importance. In connection with every method the plan
of reducing the weight of the patient due to obesity is of primary
importance.
Dr. F. H. Gerrish, of Portland, Maine.
There is a certain class of cases which gives me some concern, and
that is those of congenital umbilical hernia, which we often cure by a
simple truss, but which occasionally run on for years without a cure.
I would like to ask Dr. Mayo what he does in these cases.
Dr. De Forest Willard, of Philadelphia.
I remember performing an umbilical operation that gave me an
unusual amount of difficulty on account of the enormous obesity of
the patient, who weighed 500 pounds, and I was obliged to work
through an incision about eight inches deep through solid fat. The
operation has successfully stood the test of eight years. The case was
one of strangulated hernia in the centre of a large mass of omentum.
After reducing the bowel I drew out more omentum than had been
previously herniaized, ligated and cut it away. I could not bring the
recti muscles together on account of the fat ; consequently I fastened
the omental stump to the peritoneum at the umbilicus and made it
the plug, after freshening the sides of the opening. The huge mass
of fat and skin was drawn together by several layers of suture, and
the last I heard of the patient she had a good abdominal wall. In
ligating off the omentum it is always important to take away a larger
RADICAL CURE OF UMBILICAL HERNIA. 305
portion than has been prolapsed previously. The tendency to relapse
is thereby greatly diminished.
Dr. a. J. McCosH, of New York.
I remember a case of ventral hernia in a young fat woman from
whom there had been removed a large fibromyoma of the abdominal
wall. She came to me about three years ago with a large hernia which
she could not control on account of the large opening in the abdom-
inal wall, due to removal of the muscle. After exposing the opening
I found it was impossible to bring the muscles together, so I filled up
the gap with a celluloid plate about four by five, inserting it between
the peritoneum and the external oblique muscle, tucking it under the
edges of the latter. The plate was perforated by twenty- five or thirty
perforations made with a ticket punch. The exterior of the peri-
toneum was scraped and the skin wound sutured over it. Although
this was nearly three years ago, the woman is still perfectly comfort-
able. She wears a light abdominal bandage, and there is no sign of
irritation from the plate, nor any evidence of hernial protrusion.
While I do not recommend the method, it is a procedure which may
be tried in cases where considerable portions of the abdominal wall
have been removed.
Dr. W. B. Coley, of New York.
I have had a very large experience in the observation of these cases,
and several years ago I operated on a considerable number. The
results were bad, and at least 50 per cent, relapsed in from a few
months to a few years. Contrary to the experience of Dr. Mayo, the
after- history of my cases which relapsed were not as good as before
operation. The omentum came back and became adherent, and the
local irritation was worse than the condition before operation. The
results of operation on a large number of these cases by one of my
colleagues have convinced us that they are not improved. Of course,.
I am referring now only to large fat people, and I am sure they have
not derived any good by operations that have been done in the past..
The operation as performed in New York differs somewhat from Dr..
Mayo's. Whether or not the new operations are going to give us
better results than the old ones it is hard to determine. We are not
able to say whether the condition is benefited by the new operation,
as sufficient time has not elapsed. There is considerable risk in oper-
Am Surg 20
306 RADICAL CURE OF UMBILICAL HERNIA.
ating on some of these cases, and unless we can cure them the ques-
tion of operation is one hard to decide.
Dr. J. Collins Warren, of Boston.
It has been stated that the etiology of this condition is important,
and I am sure this is so. It has seemed to me that cases of acquired
umbilical hernia are due to the development of a large fold of abdom-
inal wall which pulls upon the umbilical cicatrix. In this way we
have the beginning of the hernia, and it is possible that we may find
less tendency if the large fold of abdominal wall is removed, as has
been done in some cases already, both for anaesthetic purposes and
for comfort. I shall look with interest to see whether cases operated
upon with that end in view have a recurrence.
As to the method of suturing, I prefer also to suture from above
downward rather than the lateral, and I think a better adjustment can
thus be made. The peritoneum should be thoroughly separated. I
have never tried the overlapping method. The suture material I prefer
is silk.
Dr. Mayo. I have not operated on cases similar to those described
by Dr. Gerrish. As to the amount of omentum to be removed,
referred to by Dr. Warren, I think we should remove whatever is in
the sac. If the sac also contains intestine which is constantly ex-
truded, we should remove enough omentum, previously contained in
the abdomen, to allow for the intestine we wish to restore.
In reply to Dr. Coley concerning relapses, I would state that I
have seen only one, and this one is very comfortable. I have never
seen any deaths, and see no reason why there should be, unless acci-
dentally. Of course, in strangulated cases there are many deaths.
I was glad to hear Dr. Warren's remarks in reference to suturing
from above downward, as I did it in this way of necessity in my first
case, against my own judgment.
PREVENTION AND CURE OF POST-OPERATIVE
HERNIA.
By JAMES E. MOORE, M.D.,
MINNEAPOLIS MINN.
A PAPER on this subject must necessarily be short because the
subject is a small one at the present time, but we can all remem-
ber when it was very large and important.
Modern surgeons very rarely see a post-operative hernia fol-
lowing their operations except after operations for acute appen-
dicitis in which they have been obliged to drain. In the
controversy between the advocates of abdominal and vaginal
hysterectomy the fear of a ventral hernia should no longer be an
argument against the abdominal route because an operator com-
petent to perform hysterectomies will not have hernia follow
his operations. All the ventral herniae I have seen during the
past three years, with one single exception, have either followed
acute appendicitis operations, in which it was necessary to drain,
or operations performed by " occasional operators." The one
exception was in a hitmophiliac who had had her wound packed
to save her life.
The causes of ventral hernia are sepsis, improper closing of
the wound and drainage. It follows that hernia is to be avoided
by asepsis, proper closing of the wound, and by avoiding drain-
age. Upon the question of asepsis we all practically agree, but
concerning the closure of the wound there are still differences
of opinion. This was very manifest in the discussion of Dr.
Richardson's paper last year. At one time it was believed that
a hernia was more frequently the result of an improperly made
or located wound than of an improperly closed one, but at the
308 MOORE,
time when we were all having some ventral herniae we were more
particular as to the location of the wound than we are now.
While we always prefer to make the wound parallel with the
fibres of the tissues, we do not hesitate to cut crosswise when a
cross incision will better expose the field of operation, for we
know that by a careful closing of the wound we need not fear
hernia. When we first began to perform appendicitis opera-
tions it was believed that our hernias were due to the cutting of
the muscles crosswise, but we can make a short cross-incision
now when operating for chronic appendicitis and, by closing
the wound accurately and aseptically, can avoid a hernia.
When we cut muscular fibres across in other parts of the body
we expect them to unite when properly approximated. Why
not expect the same of the abdominal muscles ?
The fact that every experienced surgeon believes that his par-
ticular method of closing the abdominal wound the best, proves
that when certain rational principles are adhered to the partic-
ular method of carrying them out is of less importance than we
are apt to believe. The nearer we approach nature's method
the more rational we are. We are certainly following nature's
method when we close a wound by uniting fascia to fascia,
muscle to muscle, and peritoneum to peritoneum, and we
certainly are not following nature's methods when we bury
unabsorbable material in the wound. Dr. Coley stated in his
discussion of Dr. Richardson's paper last year that he had seen
thirty cases of sinus due to buried unabsorbable sutures. We
rarely meet with a sinus in the Nort'nwest because of the uni-
versal use of absorbable ligatures and sutures.
I will describe briefly the method I have employed for several
years in closing the abdominal wound and give my reasons for
preferring it. This is also the method employed by all of the
surgeons who operate in the same hospitals with me, except
my colleague, Dr. A. W. Abbot, who uses the crossed suture of
Dr. Fowler, with some slight modifications.
The peritoneum is first closed by a running stitch of medium-
weight catgut. Silkworm-gut sutures are next passed through
all of the tissues except the peritoneum, by means of a full-
POST-OPERATIVE HERNIA. 3O9
curved needle of a size suited to the thickness of the abdominal
wall. The needle passes from without inward through the
integument, fascia, muscle, and deep fascia, coming out next to
the peritoneum. It then passes from within out through the
inner fascia, muscle, outer fascia, and integument. In a very-
thin abdominal wall the needle can be passed through both
edges of the wound at one sweep, but in most cases it is better
to take them separately. These stitches are placed about
half an inch apart. The fascia of the external oblique is next
united by a running stitch of medium weight catgut. All of
the ends of the silkworm-gut are now caught and pulled upon
at once, so that they are made taut, after which they are tied
lightly. Extra skin sutures are applied when needed.
The advantages of this method are : First, the peritoneal
cavity is closed without delay ; second, there is no unabsorb-
able material left in the tissues to make future trouble ; third,
the suturing of the outer fascia gives such support that the silk-
worm sutures need not be tied so tight as to cause necrosis ;
fourth, it obliterates all dead space, and, lastly, it yields eminently
satisfactory results. The catgut used is sterilized by the dry-
heat process of Boeckmann, and is always sterile. The advan-
tage claimed for passing the needle from within out is only
theoretical, for I have not taken the time to do this, and since
I have worn rubber gloves stitch abscesses are practically
unknown in my work.
Dr. Abbot's cross-stitch differs from Dr. Fowler's original
suggestion in two points. He first closes the peritoneum with
catgut, and, instead of tying over rubber tubes, he ties the two
ends together, just as we do in the through-and-through stitch.
After closing the peritoneum he takes a thread of silkworm-
gut with a medium-sized needle on each end, and passes one
needle from within out; first, through the deeper fascia, then
across through the muscle and outer fascia of the opposite side;
then across through the integument of the original side. He then
takes the other needle and passes it from within outward, just
as he did the first, but beginning on the opposite side. This is
an excellent stitch, for it brings the tissues together, layer by
3IO MOORE,
layer, and leaves no dead space. There are, however, two
objections to it : it requires much more time to apply it, and
causes the patient more pain when it is removed.
In most cases of acute appendicitis, drainage through the
abdominal wound cannot be avoided, but the wound should be
partly closed, leaving just sufficient room for drainage. In the
few cases of pelvic surgery requiring drainage, it is safer and
better in every way to drain through the vagina.
The same rules should govern the treatment of post-operative
hernia that apply to other varieties of hernia. When a patient
applies to a surgeon for advice the rule should be to advise
operative treatment. Mechanical treatment is unsatisfactory, and
is only palliative at best. The tendency is for the hernia to
grow larger and for the surrounding tissues to undergo changes,
so that the chances for a successful operation diminish with
time.
Until quite recently the tone of the literature upon the treat-
ment of ventral hernia was quite pessimistic, because it was
written when ventral hernia was quite common. It follows that
an operator who has had hernia follow his operations frequently
would often fail in his efforts to cure the hernia.
At the present time the prognosis in the operative treatment
of ventral hernia is good. My results since employing the tech-
nique described in this paper have been as good as those fol-
lowing operations for inguinal hernia. When we undertake to
cure a ventral hernia we should endeavor to restore the tissues
to their normal relations, and hold them there by artificial
means until nature has had time to unite them firmly. I believe
that it is unwise to go beyond this and try to assist nature
permanently by burying unabsorbable material in the tissues,
and I know from personal experience that it is unnecessary
It is just as important to enter the peritoneal cavity and remove
the sac in this variety of hernia as in any other variety. The
entrance should be made well away from the cicatricial tissue
for fear of injuring an adherent intestine. All of the scar tissue
should be dissected away, and the various layers of the abdomi-
nal wall carefully isolated. When this has been accomplished
POST-OPERATIVE HERNIA. 3II
the Operation resolves itself into the closure of an abdominal
wound. The wound should be closed by through-and-through
sutures of silkworm-gut and buried animal sutures, the method
differing from the closing of an ordinary abdominal wound only
in that the silkworm sutures should be much closer together,
and the buried sutures should be of kangaroo tendon or chromi-
cized catgut, because the tension is greater and the tissues are
not in so favorable a condition for healing.
It has recently been suggested that we use silver wire sutures
wound around a piece of ivory, together with buried sutures of
kangaroo tendon. (See Medica/ Nezvs, September i, igoo.) The
reported results are good, and the method is doubtless a good
one; but this return to the old quill sutures seems like a step
backward, and it is unnecessary.
Next to asepsis the most important step in this operation is
the separation of the various tissues by careful dissection. A
simple cutting out of the scar and bringing the freshened edges
together is very liable to lead to disappointment. It is of spe-
cial importance to bring the muscular layers together, because it
is the best protection against a hernia. We do not find this
tissue in the covering of a hernia. In a median hernia it is often
necessary to open the sheaths of the recti in order to bring the
muscles together.
After the operation the patient should be kept in bed at least
three weeks, to give the tissues ample time to heal before weight
is thrown upon them. When the patient is very fat, it is often
advisable to keep him in bed on a milk diet for three or four
weeks before the operation, just as we do in umbilical hernia in
fat people. Patients with pendulous abdomens should wear an
abdominal support after the operation, but spare persons do not
need it.
312 DISCUSSION.
DISCUSSION.
Dr. Arthur Dean Bevan, of Chicago.
As to the non-absorbable sutures, they form sinuses, it is said, and it
is claimed that to use non-absorbable gut is no longer to be regarded
as good surgery, but it has been demonstrated beyond question that it
is not the best surgery. A catgut suture can be so well prepared and
made to last a sufficient length of time to answer all purposes. I have
had the run of some seventy consecutive herniae with formalin gut with-
out suppuration. Even after extensive hernia operations of great
severity I have used the formalin gut with the best results. An inter-
esting point came to my notice within the last two years. A well-
known advocate of non-absorbable sutures was appointed to a hospital
with which I am connected, and he was soon a convert to the absorb-
able suture. What converted him, I am sure, was a comparison
between his work and our own.
I disagree with the statement that the position of the incision has
little to. do with the resulting hernia. Dr. Moore states that if the
incision is properly sutured the results are good ; but I think the posi-
tion of the incision and the amount of injury done to the nerves and
vessels of the region have much to do with the resulting hernia. We
are all familiar with the right inguinal hernise that sometimes follow
appendicitis operations, and have all seen a number of such cases. I
think the reason is clear, /. <?., that the atrophy of the tissues resulting
from the nerve injury is accountable for the herniae. The atrophy of
the rectus following incision into the linea semilunaris is well known
as is the atrophy following the cutting off of the blood-supply. I
know of several cases of atrophy of the muscles of the face following
ligation of the carotid, and I believe that the planning of the incision
so as to reduce to a minimum the nerve and vessel injury is of the
greatest possible importance. The normal lines of incision should be
followed as closely as possible, such as the midline muscle ; splitting
incision for the appendix ; the incision, usually made in the division of
the rectus, and the posterior incision to avoid injury to the intercostal
nerve and the lumbar vessels. In case of operations such as those on
the liver and spleen, in which we do not choose one of these normal
lines, we should so plan our incision as to reduce to a minimum the
danger of nerve and vessel injury. Another point has been developed
POST-OPERATIVE HERNIA. 3I3
by my colleague, and that is the use of the auto-suture, which he has
employed in a limited number of cases, but especially in operations
upon the appendix. In the inguinal hernia operation, instead of using
a suture, a narrow ribbon about one-sixth of an inch in width is
stripped off from each side of the division of the aponeurosis. This
may be made four or five inches in length, and with this ribbon the
conjoined tendon and Poupart's ligament are sutured together. Over
this the aponeurosis and the external oblique are closed with a Fowler's
suture. After removal of the Fowler's suture no material foreign to
the patient is left in the wound. Some experimental work is now
being done to determine the life-history of these ribbons. It would
seem to be an ideal method, provided they live.
Dr. Moore. Referring to my remarks in reference to the place of
incision, and to Dr. Sevan's comment in favor of following the nor-
mal line, I do not wish to be understood as in favor of deviating from
the normal. Appendicitis we always have with us, and inguinal hernia
following appendicitis is much more common' than it formerly was.
It would not be surprising if we had some strange coincidences.
FRACTURES AND DISLOCATIONS OF THE SPINE.
By S. H. weeks, M.D.,
PORTLAND, MAINE.
I HAVE been led to choose this subject because several cases
have come under my observation recently at the Maine General
Hospital and in my own practice as well. The doubt and un-
certainty which have hitherto surrounded the treatment of such
injuries can only be cleared up by a more careful study of the
nature of such injuries. Fractures and dislocations of the spine
are so frequently associated in the same patient that they are
now spoken of as fracture-dislocations.
Though dislocation of the spine apart from fracture is rare,
it nevertheless does sometimes occur. It is almost wholly con-
fined to the cervical region, occurring most frequently in the
lower half of the neck. It may be either unilateral or bilateral.
The dislocation is usually brought about by hyperflexion, which
causes the inferior articular processes of the vertebra above to
slip forward and upward on the superior articular processes of
the vertebra below.
This is rendered possible by the tearing or separation of the
intervertebral disk and laceration of the surrounding ligaments.
The displacement of the upper part of the spine is almost in-
variably forward. Unilateral dislocation is sometimes brought
about by extreme rotation of the neck. When this occurs the
head will be turned toward the opposite side and fixed in that
position, while the irregularity in the spine and in the transverse
process will be apparent. According to Dennis, about 20 per
cent, of these injuries are fractures alone, about 20 per cent, are
dislocations alone, and about 60 per cent, consist of both frac-
FRACTURES AND DISLOCATIONS OF THE SPINE. 315
ture and dislocation, and are known under the compound name
of fracture-dislocation.
Though the injury to the bones may be extensive, this is the
least important feature of the case.
As in fractures of the skull, the injury to the brain is vastly
more important, so in fracture of the spine it is the injury to the
cord which is of such vital importance. These fractures, like
fractures elsewhere, may be simple, compound, or complicated.
It is claimed that the bodies are more frequently fractured than
the arches.
Aside from positive demonstration by dissection, it would
seem almost impossible that the vertebrae, bound together by
numerous articulations and powerful ligaments and cartilages,
could be dislocated without being broken. Abernethy denied
the possibility of such a dislocation. But though this accident
is exceedingly uncommon, a sufficient number of cases have been
observed to establish the existence of this injury beyond a shadow
of a doubt.
Agnew gives a table of 24 cases of cervical luxation. Eleven
of these were verified by a post-mortem examination. The
cervical region, in consequence of the degree of movement ex-
isting between its vertebrae, and also the superficial character of
the articulating processes, furnishes the largest number of ver-
tebral dislocations. The region embraced between the fourth
and sixth cervical vertebrae, inclusive, seems to be exception-
ally vulnerable.
A dislocation may occur at any of the articulations between
the second cervical and first dorsal vertebrae. The direction of
the displacement is generally forward — that is, the vertebrae
below the one displaced remain fixed, while all the vertebrae
above are carried in an anterior direction. The manner in which
these dislocations occur would seem to show that for their pro-
duction it is necessary that great violence should be applied
either to the head while it is bent forward toward the breast, or
directly to the back of the neck. In the unilateral or one-sided
displacement the force is supposed to act more on one side —
the affected side — than on the other, as this luxation may result
3 1 6 WEEKS,
from the spine being violently twisted. In addition to the lacer-
ation of the ligaments and cartilages the cord itself may be
contused, crushed, or even severed. Blood is also extravasated
both within and without the spinal canal. The luxations which
occur above the second cervical vertebra are the occipito-atloid
and the atlo-axoid. In the three dislocations of the occipito-
atloidean articulation which have been reported the injury was
produced by violence applied to the back of the head or neck.
In the first case (that given by M. Hassus) a bale of hay fell
from a height, striking upon the back of the neck a man whose
head, at the time of the accident, was bent over upon the breast.
In the second case, recorded by M. Palletta,^ the luxation was
the result of a fall, in which the back of the man's head most
probably first struck the ground. In the third (M. Bouisson's)
case the patient was a boy, who had been crushed under a
wagon. In each case the injury proved fatal. The lesions in
all three of these cases were different. In the first there was
an almost complete separation of the condyles of the occipital
bone from the cup-shaped cavities of the atlas, with laceration
of the vertebral vessels. In the second, the atlas, though dis-
placed, was not wholly separated from the occipital bone ; and
in the third, the dislocation was unilateral, the right half of the
posterior arch of the atlas being forced against the medulla
oblongata.
Atlo-axoid Dislocations. The peculiar nature of the artic-
ulation between the atlas and axis, admitting of extensive rota-
tion, renders it particularly liable to injury from violent and
extreme twists of the head, or from similar movements of the
body when the head is flexed.
Dislocation of the atlo-axoid articulation may take place in
several ways. When the odontoid process is broken the atlas
may slide backward from the axis, carrying with it the process,
and crowding the upper part of the spinal cord. Or the odon-
toid ligament may be ruptured, together with some fibres of
the transverse portion, a lesion which will allow the odontoid
• Cooper's Surgical Dictionary.
FRACTURES AND DISLOCATIONS OF THE SPINE. 317
process of the axis to slip beneath it, even though the transverse
hgament may remain unbroken. Again, the atlas may be
rotated upon the axis to a degree which will cause a rupture of
the articular ligaments and a displacement in which the atlas
will rest obliquely across the axis, the lower articulating
process of the atlas being in front of and the other atloidean
process behind the axoid process. And lastly, the dislocation
may be limited to the articulating process of one side. Atlo-
axoid dislocations are the result of falls upon the head, strokes
or blows upon the back of the neck, sudden and extreme twists
of the head, or twists of the body when the head is held in a
fixed position. It was probably in the last-mentioned way that
the axis was displaced from the atlas, causing the instantaneous
death of a child while being raised by the head, and struggling
to release itself, in the case reported by Petit.
Dislocations of the Dorsal Vertebr.^. The secure man-
ner in which the dorsal vertebrae are locked together, the great
strength of the intervertebral cartilages and ligaments, and the
extent of their articulating surfaces, combine to render uncom-
plicated luxation of these bones a matter of great difficulty.
Very generally their displacement is associated with a fracture,
producing what is now termed fracture-dislocation. This was
the condition in most of the 13 cases collected by Malgaigne, the
verity of which was established by dissection after death. The
vertebrae in the lower part of the dorsal region are those which
suffer most, as the flexibility of the spine in this locality renders
it more vulnerable than at any point below the cervical region.
This is well illustrated by the fact that of the 13 dislocations
alluded to above, 7 occurred between the ninth dorsal and the
first lumbar vertebra.
These injuries are usually caused by extreme flexion of the
spine conjoined with the direct application of great force.
The displacement may be forward (the usual position), back-
ward, or lateral.
Symptoms of Dislocation of the Cervical Vertebr/e.
Though in many instances there must remain some doubt as to
the exact nature of the injury, yet in well-marked cases of this
3 1 8 WEEKS,
luxation the head assumes a certain position, dependent upon
the direction of the displacement — that is, it will be flexed upon
the breast when the dislocation is backward, extended or carried
backward when the luxation is forward, and turned to one side
or the other when it is a lateral luxation. A break in the line
of the spinous processes may also be detected, the dislocated
vertebra and all above it being found either in front of, behind,
or to one side of those below the seat of injury. The same
want of regularity which is noticed in the position of the spinous
processes may be seen to exist to some extent also in the
anterior surfaces of the bodies of the vertebrae by examining
the posterior wall of the pharynx. Both in dislocation and
fracture-dislocation of the cervical vertebrae, paralysis, more or
less complete, follows the injury, affecting all the parts below
the seat of injury. Death, after a lesion of this nature, may
follow almost instantly, especially when the luxation is above
the origin of the phrenic nerve, or it may be delayed for a few
days, rarely exceeding two. Of 1 1 cases which appear in the
table above alluded to, and were verified by post-mortem exam-
ination, all died at periods ranging from twenty-four hours to
eleven days, except in a single instance, when the patient lived
fifteen days. The symptoms of an atlo-axoid dislocation must
necessarily be very vague and uncertain.
Should the head be found twisted to one side and incapable
of rotation, with a bent state of the neck, and if it were known
that a sufficient cause of dislocation had been applied there
would be presumptive evidence of a unilateral displacement,
provided, however, no deformity could be felt at a lower part of
the cervical spine. Unilateral dislocation is sometimes brought
about by extreme rotation of the neck. When this occurs the
head will be turned toward the opposite side and fixed in that
position, while an irregularity in the spines and in the trans-
verse processes will be present. Pressure upon the nerves rising
between the displaced vertebrae gives rise to peripheral pain
and numbness. Varying degrees of paralysis, both of motion
and sensation up to the level of the lesion, will result from com-
pression of the spinal cord, and will depend upon the amount
FRACTURES AND DISLOCATIONS OF THE SPINE. 319
of injury inflicted. When the dislocation is unilateral the cord
may escape injury, or the damage to it be but slight. When
the paralysis is delayed for days it will probably be due to an
inflammatory effusion of serum or lymph, or to inflammatory
softening of the cord.
Treatment. In considering the matter of treatment let us
inquire what cases require operation and in what cases is sur-
gical interference cotitraindicated. In the treatment of fracture-
dislocation I believe the surgeon should perform laminectomy
in every case, if the condition of the patient is such as to justify
any operation, regarding the operation in the first instance as an
exploratory one.
The hope of restoration of function in those cases in which
the cord is not irretrievably injured depends on the promptitude
with which the cause of compression is removed ; and, how-
ever small the number of cases may be in which benefit is to be
looked for, I hold that even those few justify one in immediate
operation. Laminectomy is not a difficult operation, since the
soft parts are always found torn and quite detached from the
bone, and the introduction of cutting instruments or forceps
under the lamina is very easy from the displacement present.
When an exploratory laminectomy has been undertaken in
fracture-dislocation, and such displacement found that the re-
moval of the neural arch does not suffice to relieve the pressure
on the cord entirely, the operation can be extended to the
articular processes, so that manipulation in the wound, com-
bined with extension and rotation, may succeed in reducing the
dislocation and restoring the normal line of the spinal column.
Chipault advocates early interference if an operation is to be
done, owing to the fact that degenerative changes of the cord
take place within twenty-four hours, as has been shown by
experiments on animals and by autopsies. Laurestine believes
that even if there is incontinence of urine and feces, with cys-
titis and bed-sores, an operation is justifiable, as recovery cannot
be expected without operation. Mr. Horsley is definitely in
favor of an operation in all cases where there are symptoms
which would show pressure upon the cord. Burrell analyzed
3 20 WEEKS,
i68 cases, and advocates operation in the first twenty-four hours
in all cases of fracture, even including those in the cervical
region. Thornburn has reported 6i cases of operation, with 35
deaths; Chipault has collected 95 cases, with 38 deaths; Lloyd
has found mortality of 57 per cent, after operation. The oper-
ation consists of laminectomy for the purpose of removing from
the cord the pressure of extravasated blood or loose spiculse of
bone. The danger from an operation increases with the height
of the lesion. Reider reports the case of a tiler who fell from
a second story. There were somnolence, paraplegia, and anjes-
thesia of the lower extremities ; the fifth and sixth dorsal spines
were prominent; vesication soon began to form.
Sixteen hours after the accident the fractured spinous proc-
esses and laminae were resected, removed, relieving the com-
pression of the spinal cord, which was already somewhat soft-
ened. The symptoms, with the exception of the paralysis of
the bladder, at once improved, and on the sixth day the urine
and feces were discharged voluntarily. A plaster-jacket was
applied, and four months later the patient attempted to walk.
Two months afterward he still had a slow and spastic gait,
using a stick.
A better result was obtained in a case reported by Huss, in
which a man, aged thirty four years, had fallen a distance of
twelve feet, producing a fracture-dislocation at the junction of
the dorsal and lumbar region, with paraplegia, paralysis of the
rectum and bladder, and an enormous slough over the sacrum.
A month after the accident the arches of the tenth and
eleventh dorsal vertebrae were removed, the cord was found
angulated, the dura was not distended, and was left unopened.
Immediate relief was experienced ; all the symptoms subsided,
and two or three months later the patient was able to walk
perfectly well, and the spinal column presented no deformity.
A very interesting case of laminectomy for fracture-disloca-
tion, with a good result, is reported by Knox. The patient was
a boy, aged thirteen years, injured in a pit by a " cage " falling
upon him and doubling him up. The eleventh dorsal vertebra
projected distinctly ; both sensation and motion were lost in the
FRACTURES AND DISLOCATIONS OF THE SPINE. 32I
lower extremities, but the bladder was under control. On the
second day the spinal column was laid bare at the seat of injury,
and the body of the eleventh dorsal vertebra was found broken
across ; the upper articular processes were also broken ; there was
displacement backward, with some rotary complication. The
laminae of the tenth vertebra were sawed through, but the dura
was not opened ; careful extension was made, and the fragments
pushed into proper place. Pulsation was at once restored in
the cord, and the next day sensation was perfect in the lower
limbs ; but the power of movement, except of the toes, was not
regained for nearly two months.
At the time of the report — almost a year after the accident —
the boy was able to stand erect, and even to take a few steps
without any support ; the movements of the ankle and tarsal
joints were still very limited. Knox thinks, and it would seem
with reason, that the injury sustained was' chiefly in the anterior
columns of the cord, about the middle or lower part of the
lumbar enlargement. The recovery of movement, as well as of
the size and firmness of the muscles, took place gradually from
above downward.
A successful operation for fracture of the third lumbar ver-
tebra, the Cauda equina being compressed by callus, which was
removed with difficulty after stripping away of the laminae of
the second, third, and fourth lumbar vertebrae, is recorded by
Starr. The operation was performed a year after the occur-
rence of the injury; at the time of the report the man had a
fair control of the rectum and bladder, the paralysis had almost
disappeared, and anaesthesia alone remained. Lane reports a
case in which an operation was performed for a fracture dislo-
cation of the spine. The symptoms came on gradually after the
injury and rapidly increased in severity. It was found that the
tenth dorsal vertebra was displaced forward and slightly down-
ward, so that the cord was compressed between the laminic of
the tenth and the body of the eleventh dorsal vertebrae The dis-
placement was not very great, so that the cord was apparently
squeezed rather than crushed. The interspinous ligament was
torn through. After great difficulty the tenth dorsal vertebra
Am Surg 21
322 WEEKS,
was brought back into its normal position. This was effected
partly by overextending the dorsal spine and partly by traction
exerted upon the spinous process by lion forceps, and the
spinous processes were tied together. Thirteen days later he
appeared to have recovered complete control over his legs.
The spinous processes were in good position over the same
transverse plane. The reflexes were then normal. The patient
kept constantly rolling about, and complete paraplegia soon
developed. The wound was explored, when the vertebrae were
found to be displaced laterally upon one another, and the cord
was completely divided. This unfortunate result was due to the
extremely troublesome character of the patient, whom it was
found impossible to control by any means.
Wyeth reports the histories of three cases of fracture of the
spine in which he had operated. The first was that of a man,
twenty-two years of age. In 1890 the patient was struck by
the pilot of a locomotive, and fractured the second lumbar
vertebra, and had been immediately paralyzed from that point
down.
Two years later the eleventh and twelfth lumbar arches were
removed, and found the cord compressed by dislocation of the
body of the second lumbar vertebra; six hours later improve-
ment had begun, and now, the patient, though far from being
perfectly well, was able to get about, and had been greatly
improved by the operation.
Vincent reports three cases in which he operated on the spine
for penetrating gunshot wound with injury to the cord. In the
first case, which was one of injury to the first lumbar vertebra,
removal of fragments of bone and of the bullet from the spinal
canal was followed by complete recovery. In the other two
cases — each of penetrating wound in the lower part of the
dorsal region, with laceration of the cord and its membranes —
similar treatment was followed by death, in one on the eleventh
and the other on the fourteenth day.
Hammond says that pressure prolonged for any length of
time invariably causes degeneration, both ascending and de-
scending, of the different tracts of the cord. Relief of the
FRACTURES AND DISLOCATIONS OF THE SPINE. 323
pressure is not followed by any diminution of the degeneration.
But relief of the pressure prevents the process of degeneration
from beginning. Hence, the surgeon should operate as soon
as possible after the injury to the cord has been received.
Lloyd, after a study of 103 cases, agrees with Horsley, that
operation should be undertaken at once " in all cases when dis-
placement or crepitus indicates compression, and when exten-
sion directly after the accident clearly fails to reduce the
deformity," provided there are symptoms present which indi-
cate interference with the function of the cord. In other cases,
the operator should wait until the shock following the injury
has been overcome. During this time, however, the patient's
condition should be most carefully watched, and the first indi-
cation of any symptoms pointing to the extension of the inter-
ference with the function of the spinal cord, whether that
interference be due to hemorrhage or myelitis from com-
pression.
A Report of One of My Own Cases.
August 29, 1900, Mr. C. P., aged seventy years, fell from a ladder,
a distance of about twelve feet, striking on his right shoulder and
right side of the head. He was rendered partially unconscious, and
while in this condition was carried into the house, when it soon
became apparent that he had sustained some serious lesion somewhere
in the cervical region. The head was thrown slightly backward,
turned sharply to the right, and before operation held firmly in this
position. The left upper extremity was paralyzed as to motion ; sen-
sation was apparently good. Motion in right upper extremity fairly
good ; motion in lower extremity also fairly good. He was, however,
unable to pass his urine, the use of the catheter being required. There
was great pain in the left arm and hand. Nine days after the injury
I saw him in consultation with the attending physicians, and found
the condition which I have described above, and also found a de-
formity of the cervical spine at about the fourth vertebra ; it seemed
like a dislocation, and as if there were a fracture with a fragment of
bone pressing upon or had injured the spinal nerve-supply to the
left upper extremity. An operation was thought advisable to see if
the condition could be improved.
324 WEEKS,
The next day, September 8, 1900, I made the operation. The
laminge of the third and fourth cervical vertebrae were found broken
and depressed. These were removed and the cord relieved of all
pressure so far as possible, and the wound closed without drainage.
The position of the patient during the operation was upon the face.
As I was closing the wound the patient became badly cyanosed and
the pulse feeble. He was turned upon the back, J^ grain of strychnine
given hypodermically, and he was soon breathing regularly, and no
further trouble was experienced. The seventh day after the operation
the patient had a slight chill, became cyanosed, with a weak pulse.
He complained of numbness of the lower extremities, especially the
left side. Strychnine (g?^ of grain) was given subcutaneously, and
repeated in half an hour. In the afternoon of the same day his tem-
perature was 102.4° ; respiration, 28; pulse, 108. The dressings were
removed for the first time, and it was found that the wound had healed
by first intention. The lower stitches were removed, thinking there
might be some retained fluids that had caused the sudden rise in tem-
perature. Some bloody serum escaped from the wound. Soon after
this the temperature fell to 100.4°. The next day the bowels were
freely moved with Hunyadi water, and the temperature became nor-
mal. During this attack the left leg became partially paralyzed.
Strychnine (-^-^ of grain) and quinine (2 grains) were given three times
in the day. The wound was irrigated and dressed every day with a
strip of sterilized gauze for drainage. I am satisfied that it would have
been better had I put in a gauze drain at the time of the operation, as
the man was large and muscular, and the wound deep and hard to
close without leaving spaces between the divided tissues. At the end
of the sixth week from the time of the operation the wound was entirely
healed. The fourth week the patient had an attack of cystitis. This
was reduced by irrigation of the bladder twice a day with normal salt
solution, with 5 grains of salol four times a day.
The fifth week the patient was able to sit up in a chair three or four
hours each day. There was good motion of the head, lower limbs,
and right arm ; but no motion in the left arm. At the end of the
sixth week he was able to sit up from four to six hours each day, and
was also able to take a few steps with assistance. At this time he had
a little motion in the fingers of the left hand.
From a letter received from his son, and signed by the patient him-
self, dated November 15, 1900, two and a half months after the injury,
I quote the following : " My father's condition now, as compared with
FRACTURES AND DISLOCATIONS OF THE SPINE, 325
that before the operation, is an improvement of 75 per cent. He has
a good appetite ; can eat anything he wants ; has gained a good deal
in strength ; can walk short distances by being supported on either
side. His left leg bothers him some, and both legs are somewhat
weak. The right hand and arm are nearly normal. Can write his
name legibly. There has been some improvement in the motion of
left hand and arm ; can move forearm some by having it supported.
His greatest trouble is pain in his left shoulder, arm, and hand. He
can support his head and turn it fairly well in either direction ; wound
in neck entirely healed, and lameness in cords and muscles seems to
be growing less daily. His head was turned sharply to the right before
the operation and firmly held in that position. The action of the
bladder is now normal."
Technique of Laminectomy, The greatest possible care
should be taken to have the operation thoroughly aseptic. No
operation demands greater care in all its details.
The shock of the operation is almost always severe, hence
every precaution must be taken to avoid it,
Mr. Horsley has called attention to five special dangers.
First, that of hemorrhage. This is always considerable in
amount ; but by means of haemostatic forceps, and by pressure
by means of gauze and sponges dipped in hot water, it may
easily be controlled. Second, difficulty in clearing the spinal
canal. With care and patience the difficulty can be over-
come. Third, physical difficulties in treating the fractured ver-
tebrae. In many cases the vertebrae are hopelessly fractured
and displaced, and cannot be dealt with satisfactorily. Unfortu-
nately, we are not always or even often able to judge of the
severity of the fracture until it has been revealed by the opera-
tion. Fourth, the hopeless nature of the injury to the spinal
cord. In the majority of cases of fracture-dislocation the cord
has been injured beyond the possibility of repair. Fifth, the
danger of septic infection.
With the observation of modern aseptic surgery there should
not be much danger of septic infection, excepting in compound
fractures where infection has taken place before the surgeon
sees it, or in those cases in which a fistula results from too
326 WEEKS,
long use of the drainage-tube ; as a rule, this should be re-
moved within twenty-four or forty-eight hours. Sixthly, to
these dangers White has very justly added the danger of anaes-
thesia in the prone position, the abdominal muscles being par-
alyzed. This is a very real danger, and was well illustrated in
one of my own cases, in which the patient stopped breathing
and came near dying before the operation was completed. The
depressed fragments of bone had been removed, the cord liber-
ated, and I was in the act of closing the wound when respira-
tion suddenly ceased. The wound was immediately covered
with sterilized gauze, he was turned on his side, the tongue
pulled forward, and soon restoration was restored. The sewing
up and appliance of dressing were made with the patient on his
side. No further trouble was experienced, and my patient made
a good recovery. The instruments which will be needed are
hsemostatic forceps (two dozen), scalpels, rongeur and other
bone forceps, raspatories, and a half-inch trephine, retractors,
needle and needle-holder. It is claimed by some that the
patient should be placed in Sims' position, but I have always
placed my patients in the prone position, having the face
brought to the edge of the table.
A hypodermic syringe charged with -^^^ grain of strychnine
should be at hand. The patient should be well protected by
blankets and hot-water bottles, care being taken not to burn
the patient, which has, unfortunately, happened several times
in my experience. Everything being ready, an incision is
made in the median line of the back, directly over the spinous
processes, from four to six inches long, and as much longer as
the extent of the operation demands. The resection should not
be limited to one or two arches, but should be a large one,
often involving the removal of five or six arches. I have
always found a simple linear incision sufficient. Chipault has
pointed out that in a normal spine the arches are of little value
in producing solidity of the spine, but that when the bodies are
gone, as in Pott's disease, the arches replace the bodies to some
extent in securing a solid spine.
The muscles are first separated from the arches on one side;
FRACTURES AND DISLOCATIONS OF THE SPINE. 327
this is packed with gauze to control hemorrhage, and the mus-
cles on the other side are separated from the bones, and this in
turn is packed.
By the time the second dissection has been made and the
wound packed the first will be ready for the final clearing of
the arches. Mr. Horsley claims that the separation of the
muscles from the arches should not be done with a blunt
raspatory, but by clean cuts of the knife. This is important,
because the spinal muscles consist largely of slips running
short distances, and any blunt instrument leaves the tissues in
tatters which are likely to undergo necrosis. When the mus-
cles have been well separated from the arches with the knife a
raspatory can then be used with advantage to scrape away the
remaining muscular tissue which still adheres to the bone, and
thus obtain a clear field of operation. During the first stage of
the operation the hemorrhage is very free. Large arteries may
be seized by an assistant with haemostatic forceps, but the
operator should not waste any time by attempting to do so.
The more quickly he exposes the bone and packs the wound
the less will be the amount of blood lost. I have usually de-
ferred the final cleansing of the arches until after the hemor-
rhage has been arrested. To make an opening into the spinal
canal the trephine may be used, one edge being placed close
against the spinous process, lest the intravertebral nerves
should be wounded by the penetration of the trephine. The
interspinous ligaments are best divided by a pair of blunt-
pointed scissors, there being less danger of wounding the cord
and its membranes than when the knife is used. Having iso-
lated one of the spinous processes, it may be quickly removed,
together with a part of one of the arches, by the rongeur for-
ceps. As soon as an opening is made into the canal the arches
may be quickly removed by means of ordinary bone-forceps or,
still better, by rongeur forceps, such as are used for linear crani-
otomy. The arches being removed, a somewhat thick layer of
fatty tissue lies over and obscures the membranes of the cord.
In it lies a plexus of veins which sometimes give some trouble,
but the hemorrhage is easily controlled by gauze pressure.
328 WEEKS,
The fatty tissue is best treated by carefully dividing it in the
median line, pressing it to each side, and packing with small
strips of sterilized gauze.
The dura should now be carefully examined to see whether
it pulsates. If there is no pulsation it is generally due to ad-
hesions or some other cause of interference with the continuity
of the subdural space. If there is blood within the dura the
membrane will present a bluish or purplish hue; if pus, yellow-
ish. If a tumor is present or there is any increase in the quan-
tity of cerebro-spinal fluid the increased tension and elasticity
of the dura will be perceptible to the touch. The membranes
and the cord may now be carefully drawn first to one side and
then to the other by means of an aneurism needle or any simi-
lar instrument, in order to expose the bodies of the vertebrae for
observation, or, if necessary, for operation. The nerves are
sufficiently elastic to allow of moderate stretching as the cord
is moved to one side and then to the other. Chipault places
two cushions under the abdomen of the patient, some distance
apart, so that the spine is concave posteriorly, which will facili-
tate the displacement of the cord. Whether the dura should
be opened is a more serious question in the spine than in the
brain. In the latter the opening can be closed without drain-
age, and thus we can prevent the continuous escape of the
cerebro-spinal fluid. After an operation upon the spine the
injury to the thick muscles will usually prevent primary union,
and so favor the formation of a fistula, and the wound is so
extensive and deep that drainage is usually required, and a
strip of sterilized gauze is the best, which can usually be re-
moved in two or three days or at the time of the first change
of dressing. The mere temporary escape of the cerebro-spinal
fluid is not in itself dangerous. I have seen a large quantity
lost at the time of the operation and continuously escape for
some days afterward without any ill effects. But if a fistula
results, and the cerebro-spinal fluid escapes continuously, this is
a source of annoyance and irritation to the surrounding skin,
and requires constant redressing, and has one far more serious
source of danger — namely, that it is almost impossible in re-
FRACTURES AND DISLOCATIONS OF THE SPINE. 329
peated dressings to avoid infection, which may lead to menin-
gitis, myelitis, and often death. Notwithstanding these objec-
tions, it is claimed by most operators that the dura should
generally be opened. The best result I ever had was 'in a case
of fracture-dislocation in the middle cervical region, when I did
not open the dura because the dura was so distended with what
I believed to be cerebro-spinal fluid, and was in such close prox-
imity to the brain. When the dura is opened and the operation
completed, the opening in the dura should be closed, if possible,
with a continuous catgut suture in order to secure immediate
union. If the dura is not opened we cannot learn the exact
condition of the subdural space and the cord itself.
Having opened the dura the canal can be explored carefully
by an ordinary bent probe. So, too, the extradural space
between the dura and the laminae should be explored in order
to determine whether there are any irregularities or obstruc-
tion, fracture, dislocation, etc. If the cord has been crushed or
injured by accident, any splinters of bone should be removed,
and any considerable irregularity due to dislocation or fracture
of the bodies of the vertebrae should be carefully removed by
the gouge or chisel. Attempts have been made by several sur-
geons to suture the cord itself, but without success. Leckey
has even gone so far as to propose to shorten the spine by
removing a part or the whole of a vertebra, or portion of two
vertebrae, by gouges or drills, a procedure which is only men-
tioned to be condemned. The nerves, when they have emerged
from the cord, are peripheral nerves, and should be treated by
suture, when divided, just as in any other part of the body.
Sometimes it may be better not to suture the theca, but to
leave it open, the purpose being to relieve the increased press-
ure on the cord from its swelling. No harm has come from the
escape of the cerebro-spinal fluid when the incision in the dura
has been left open ; no drain should be inserted within the theca.
A wick of sterilized gauze should be placed in the muscular por-
tion of the wound to carry off" the abundant wound fluids of the
first twenty-four or forty-eight hours. At the end of this time
it had better be removed.
330 WEEKS,
In closing the wound the muscles should be approximated
by buried catgut sutures, the skin sutured by silkworm-gut,
and the usual dressing applied. The position of this patient,
which will be nearly dorsal, happily favors drainage.
After-treatment. On account of the free oozing of the
wound fluids, and sometimes of the cerebro-spinal fluids, the
wound will have to be dressed within the first twelve hours,
after the first day not usually more than once in two or three
days. At these subsequent dressings the strictest antisepsis
must be observed, lest infection should follow. This is particu-
larly necessary if there are bed-sores, since they produce foul
discharges which may infect the wound. If the patient has
lost control of the bladder and bowels, which is usually the
case, it being necessary to use the catheter, an additional source
of infection exists, which will require great watchfulness.
The spine is best supported during the healing process by
plaster-of-Paris dressing or by sand-bags placed on each side of
the patient. In one of my patients with a fracture-dislocation
of the cervical spine, above reported, the parts were supported
by a sand-bag on each side of the head and neck. The usual
precautions as to food and drink must be observed, together
with the use of opiates, for the relief of pain, and such other
symptomatic treatment as may be indicated.
Conclusion. Though dislocation of the vertebrae without
fracture is rare, it nevertheless does sometimes occur. Dislo-
cation without fracture is almost wholly confined to the lower
half of the cervical region.
The dislocation is usually brought about by hyperflexion,
which causes the inferior articular processes of the vertebra
above to slip forward and upward on the superior articular
processes of the vertebra below.
The displacement of the upper part of the spine is almost
invariably forward.
About 20 per cent, of these injuries are dislocations alone,
about 20 per cent, are fractures alone, and about 60 per cent,
are fracture-dislocations (Dennis).
FRACTURES AND DISLOCATIONS OF THE SPINE. 33I
In these injuries the great danger h'es in compression and
laceration of the cord.
In the dorsal and lumbar regions the dislocation is very gen-
erally associated with fracture.
The most prominent symptom is paralysis, more or less com-
plete, affecting all the parts below the seat of injury.
Death may follow almost instantly, especially when the lux-
ation is above the origin of the phrenic nerves. When the
paralysis is delayed for several days, it will probably be due to
an inflammatory effusion of serum or lymph, or to an inflam-
matory softening of the cord.
Treatment. The surgeon should perform laminectomy in
every case, if the condition of the patient is such as to justify
any operation, regarding the operation in the first instance as
an exploratory one. The hope of restoration of function in
these cases, in which the cord is not irretrievably injured, de-
pends upon the promptitude with which the cause of compres-
sion is removed ; and however small the number of cases may
be in which benefit is to be looked for, even those few justify
one in immediate operation.
Laminectomy is not a difficult or dangerous operation. The
greatest possible care should be taken to have the operation
thoroughly aseptic. No operation demands greater care in all
its details. In making the operation, resection should not be
limited to one or two arches, but should be a large one, often
involving the removal of five or six arches. The membranes
and the cords can be carefully drawn first to one side, and then
to the other in order to expose the bodies of the vertebrae for
examination and, if necessary, for operation.
Whether the dura should be opened is a more serious ques-
tion in the spine than in the brain. It is claimed by most opera-
tors that the dura should generally be opened. When the dura
is opened and the operation completed, the opening in the dura
should be closed, if possible, so as to secure immediate union.
There are exceptions to this rule. Drainage is usually required,
and a wick of sterilized gauze is the best, which can be removed
in two or three days, or at the time of the first change of dress-
332 WEEKS,
ing. At the subsequent dressings the strictest antisepsis must
be observed. The spine is best supported during the healing
process by plaster-of-Paris dressing, or by sand-bags placed on
each side of the patient. The usual precautions as to food and
drink must be observed; opiates for the relief of pain, care in
relief of bladder and bowels, and the preventing of bed-sores.
FRACTURES AND DISLOCATIONS OF THE SPINE. 333
DISCUSSION.
Dr. John C. Munro, of Boston.
In opening the discussion on this subject, I shall emphasize the radi-
cal or operative rather than the conservative or non-operative treat-
ment, because up to the present time the advocates of the latter policy
have not conclusively shown that better results are to be expected than
where there has been surgical interference. I would not have you con-
clude from this that all traumatic cases should be subjected to opera-
tion ; there are contraindications not only in the local conditions, but
in the various general conditions, that militate against any operation,
but these contraindications should be weighed and judged by the sur-
geon and not by the specialist, whether neurological or medical, and
upon the surgeon should be placed the final responsibility of oper-
ating.
We must start at the very outset in fracture-dislocation of the spine
with this general equation, that all such injuries are perhaps the most
serious as regards restoration of function with which we have to deal,
and that the outlook, both as regards function and life, is bad under
any form of treatment. We must not lose sight of this equation at any
time.
It is a common argument and one not easily answered — but the
argument is none the less fallacious — that recovery after operation
would have taken place equally well without operation. As a matter
of fact, there are very few surgical conditions that will not at times
recover spontaneously. A strong counter-argument is the not inconsid-
erable number of recorded cases treated conservatively for weeks or
months without gain that have steadily and surely improved after oper-
ation ; not always propter hoc, perhaps, but with every clinical evidence
that the operation has proved the turning-point. Take the worst type
of injury, for example, that in the cervical region. To say that the cases
reported by Winnett, Horsley, McCosh, Mixter, Hough and others
would have done as well without operation as with operation does not
appeal to one's surgical instinct.
The risk of the operation, /ifr se, may be disregarded, provided the
initial shock of the accident has subsided. The number of my own
cases, twenty-one in all, may be too small from which to draw definite
conclusions on some mooted points, but it is plenty large enough to
334 DISCUSSION.
answer one question with regard to the operation : the question of
shock. I can recall only one patient in whom there was a temporary
anxiety as to his condition.
In spite of all the brilliant neurological work that has been done
within the last few years it is not yet possible to absolutely state the
exact amount or nature of the damage done to the cord. There are
symptoms like total loss of the deep reflexes that seem to indicate a
total destruction of the cord, and yet an occasional recovery in such
a case makes one hesitate to accept the hard-and-fast rule that it is
useless to operate where this symptom is present.
I am glad that Dr. Weeks advocates operation on the basis of
exploration, if for no other reason. No matter who the neurologist,
or who the surgeon, there is bound to be, every now and then, a case
beyond accurate diagnosis, just as we so frequently see in abdominal
lesions, and if we can assure the patient that exploration is scarcely
more serious in the one condition than in the other, we have a firmer
basis for advising exploration in injuries to the spine.
I doubt if opening the dura materially increases the risk of the
operation. I have never hesitated to open it, and recently I have not
even troubled to close it by suture, and, so far, there has been no ill
effect. Where the dura is tense and without pulsation I look upon a
free opening much as upon an opening of the cerebral dura. If the
dura is not distended, but there is reason for a more complete exami-
nation of the cord itself, there need be no hesitation in carrying out
this step. Furthermore, we cannot disregard the possible effect of a
greatly increased intradural pressure upon a cord already injured, but
perhaps not irretrievably so. The relief of this pressure may mean much.
Whether the dura is open or not, I close the outside wound with
deep sutures, through and through, allowing for a temporary thin
rubber tissue drain.
Dr. Weeks has referred to the rarity of dislocation without fracture.
One of my cases, already reported, showed this condition at autopsy,
the cord in the upper cervical region being almost completely crushed,
and yet without any sign of fracture of the bony column.
I still believe the technique to be of importance, but as I have
already explained that in a published article, it is not necessary to
repeat it here. I would merely emphasize the advantage of the prone
position, with the chest resting on pillows and the head supported
over the end of the table by the ansesthetizer. Packing for ha^mo-
stasis ; rapidity and cleanliness are indispensable.
FRACTURES AND DISLOCATIONS OF THE SPINE. 335
Dr. Pontico, of Troy.
That some of these cases can be cured and gotten into good shape
without operation, was proven to me from a case that came under my
observation where a man had fractured his cervical vertebra by falling
upon a wagon. He was completely paralyzed from the site of injury
down. I put him in bed on an inclined plane, shaved his head and
scalp, put adhesive plaster from the site of the accident over the whole
scalp; put on a fifteen-pound weight and kept up perpetual extension.
The man made a perfect recovery, and died some years later of dis-
ease of the liver. An autopsy was obtained, and the fourth, fifth and
sixth vertebras were found to have been fractured. They were all con-
solidated, and the man's functions were perfect. I may mention that
he never could rotate his head, but always had to turn his body, prob-
ably due to inflammatory exudates.
I have had two similar cases, one occurring in the same way as the
last, and I am sure they might have been saved in the same way if they
would have submitted to the treatment.
Dr. S. J. MixTER, of Boston.
I wish to emphasize the remarks made in favor of operation. All
cases of fracture in the cervical region should be operated upon, if
they can be seen in time, or when the temperature is not running up
to a fatal termination.
A case recently reported by me of laminectomy for fracture of the
fifth and sixth vertebrae was very instructive. The boy broke his back
by falling, and there was absolute loss of sensation, motion and reflexes.
The case was about as unfavorable a one to look upon as you could have.
He entirely recovered after laminectomy, with the exception that he
has v/rist- and toe-drop on one side. It has been claimed that these
cases would recover without laminectomy, and this is possibly true.
The bone in this case was driven down on the cord, and when the dura
was opened no crushing could be seen, but considerable bloody fluid
escaped. I think it is better not to sew up the dura after it has been
opened, but to leave it open and to drain so as to relieve possible
pressure.
Dr. R. H. Harte, of Philadelphia.
I have listened with a great deal of interest to Dr. Weeks' very
instructive paper, and I strongly indorse the remarks which he made
336 FRACTURES AND DISLOCATIONS OF THE SPINE.
in favor of early operation, as I feel convinced that much benefit can
be done to cases which otherwise would be absolutely hopeless if
prompt operation were neglected. A case is now in my ward in which
a gunshot wound was received, severing the cord in about the mid-dorsal
region. In this case there was a loss of substance of over half an inch.
The contused ends of the cord were freed and the clean surfaces
approximated with catgut sutures. This may seem almost paradoxi-
cal, but now it is very evident that regeneration of the cord is slowly
taking place, as sensation and motion are markedly present. I feel con-
vinced that our knowledge of cord regeneration is in its infancy, and
that much can yet be learned in regard to the surgery of the spinal
cord future.
Dr. Weeks. I might mention that the man on whom I operated
was aged eighty years. I believe the majority of surgeons advise open-
ing the dura, but there are exceptions to this rule. Exception obtained
in my case, inasmuch as the operation was done at the patient's home,
where I did not feel sure of my asepsis. Under those circumstances
the opening of the dura had better be omitted, unless there are dis-
tinct indications for opening it. Personally, I should hesitate about
opening it under such circumstances.
RADICAL CURE OF INGUINAL AND FEMORAL
HERNIA, WITH A REPORT OF EIGHT
HUNDRED AND FORTY-
FIVE CASES.
By WILLIAM B. COLEY, M.D.,
NEW YORK CITY.
The decade that has just passed may be said to have practically
settled the question as to the possibility of curing inguinal and
femoral hernia by operative methods of treatment. Prior to
this time, although numerous methods had been enthusiastically
advocated, and had been tried, even with all the advantages of
antiseptic technique, the results were such as to go far toward
justifying the opinion of the most conservative and judicial
surgeons, that these operations were not entitled to the term
"radical cure," and were often of very doubtful efficacy. To-
day the whole attitude of surgeons toward the operative relief
of hernia has entirely changed, and the general practitioners
as well are waking up to the fact that the time has now come
when, instead of selecting special cases of hernia for operation,
they had better select special cases for truss treatment, and
otherwise prescribe the remedy to seek operative relief. This
change has been due to two factors : first, the steady decrease
in the mortality attending operation, and second, the vastly
improved results that have followed improved methods and
improved technique.
Whereas ten years ago the mortality of operation for non-
strangulated hernia in four of the largest London hospitals was
6 per hundred, to-day, in competent hands, the mortality is less
than yi per hundred, or practically nil in uncomplicated cases.
The early mortality was sufficient to deter conservative sur-
Am Surg 2a
338 COLEY,
geons from advising operation in persons but little inconveni-
enced by wearing a truss, and when, in addition to this, there
was the fact that 40 to 50 per cent, of the cases relapsed within
two or three years after operation, it was no wonder that many
patients who understood the situation were unwilling to try
operative treatment.
In no department of abdominal surgery the world over has
there been more earnest and untiring work done than in the
operative treatment of hernia, and, although I believe that the
method introduced by Bassini in 1890 marks the highest point
in the evolution of an ideal operation for hernia, much honor
and credit are due to other men who have devised methods but
little short of his in value.
I shall first consider the radical cure of inguinal hernia in the
male. What are the indications for operation ? A decade ago
operative treatment was restricted to very large hernise or to
irreducible hernia, or hernia difficult or impossible of control
by mechanical means. To-day the indications are much wider
in scope. I would advise operation in all adults under fifty
years of age in good health, except in cases of very large, irre-
ducible scrotal hernia. I would also except very large reducible
hernia of long standing, in which the reduction of the contents
into the abdomen materially increases the tension of the abdom-
inal walls and interferes with respiration. Operation in these
cases is not free from risk, and the chances of obtaining a per-
manent cure are slight. On the other hand, there are many
patients, even up to the age of seventy, with hernife which,
though not of great size, are very difficult to control with a truss,
and the danger of strangulation is ever present. Such patients,
if in good health and not too obese, are proper subjects for
operative treatment.
The indication for operative intervention in children requires
separate consideration. When I published, in 1893, my first
paper upon the radical cure of hernia in children, with a
report of 5 i cases, the criticism was made by some surgeons
that hernia in children should not be operated upon, inas-
much as it could always be cured by mechanical means. As
RADICAL CURE OF INGUINAL AND FEMORAL HERNIA. 339
a reply to this criticism I made an analysis of upward of 15,000
cases of hernia in adults observed at the Hospital for Ruptured
and Crippled, in New York, with a view of ascertaining, as nearly
as possible, how many gave a history of hernia in infancy and
childhood. A careful study of these cases warranted the con-
clusion that at least one-third of all infants and children under
fourteen years with inguinal hernia are not cured by mechani-
cal treatment, and hence the employment of operative methods
in hernia occurring in children is entirely justified, provided
those methods are free from risk. The only death I have had
in upward of 500 hernia operations in children was due to
double pneumonia following ether. Therefore, it may safely be
stated that the risk is not appreciable.
Since the publication of the paper referred to there has been
a constant tendency to extend more and more radical cure
methods to children, until at present we are regarded at the
Hospital for Ruptured and Crippled as ultra-conservative. In-
stead of operating upon the majority of children and infants, as
is recommended by many of the French surgeons, and is the
practice of not a (qw American surgeons, our plan is to operate
very rarely under the age of four years. Most patients with
inguinal hernia under the age of four years may be cured with
a truss, and it is well to give them the trial. After the age of
four years and up to fourteen years we advise truss treatment
for one or two years, at the end of which time, if the hernia
still comes down and the ring is large, we believe there is little
to be gained by waiting, and advise operation. Among dispen-
sary patients it is often difficult to provide the proper care at
home in the management of the truss necessary to success, and
in such cases the question of operating earlier may be left to the
judgment of the surgeon.
Adherent omentum, though comparatively rare in children,
is occasionally met with, and when present operation should be
performed without delay.
Reducible hydrocele or fluid in the hernial sac is more fre-
quently seen, and this condition precludes the hope of cure by
truss treatment, and calls for operation.
340 CO LEY,
Methods Employed. I have already in former papers dis-
cussed the relative value of the various methods of operation for
radical cure, and at present shall do little more than describe the
methods personally employed in the cases reported. Time is
wasted in a theoretical discussion of the relative value of the dif-
ferent methods of operation for the radical cure of hernia. The
value of a method can neither be determined by the reputation of
the surgeon who has originated it, nor by the distinction of the
men who accept it. It can be settled only by a scientific analysis
of results subjected to the test of time. By time I do not mean
the number of years since the operation was performed, but the
careful tracing of patients to final results or for long periods of
time.
The chief object of this paper is to furnish, by the presenta-
tion of a considerable number of cases operated upon by a single
method and uniform technique, additional data that may be of
help in solving the question of choice of methods in the radical
cure of hernia.
The method of Bassini, when first published, appealed to me
strongly as superior mechanically to any hitherto described, and
his practical results seemed to bear out the theoretical supe-
riority.
The chief advantage, to my mind, is the fact that the only
weak place in the wound, viz., where the cord emerges through
the internal ring, is protected by the overlying layer of the
external oblique aponeurosis, so that a recurrence can only take
place by the hernial protrusion forcing itself directly through
the aponeurosis at this point or taking a right-angled course
downward beneath the external oblique. With perfect wound-
healing this ought never to occur, and we find in actual prac-
tice it very seldom does. However, to correct, as far as possible,
this one weak point of the operation, I have slightly modified
Bassini's technique by introducing a single suture above the
cord, bringing the internal oblique muscle into apposition with
Poupart's ligament above the cord, thus making the cord come
out between the two upper sutures. The only other change that
I have adopted has been the substitution of an absorbable suture —
RADICAL CURE OF INGUINAL AND FEMORAL HERNIA. 34 1
chromicized kangaroo tendon — for the silk sutures originally-
employed by Bassini, and which he still uses. The advan-
tages of absorbable sutures I will discuss later. In introducing
the deep layer of buried sutures the first stitch is placed so that
it just touches the lower edge of the cord when the latter is held
vertically to the plane of the abdomen. This furnishes a uni-
form guide as to how high up the canal the sutures should go.
The sutures are introduced from within outward by a full curved
Hagedorn needle without a holder, and the index finger of the
left hand passed just beneath the muscles guards the peritoneum
from harm. Four to five sutures suffice below the cord, and one
above. The aponeurosis is closed also from above downward,
but with a continuous suture of kangaroo tendon of fine calibre.
The skin is closed with No. i catgut, without drainage. A
dressing.of 10 per cent, iodoform and moist i : 5000 bichloride
gauze is then applied, and the wound not dressed until the
seventh day. In children a plaster-of-Paris spica is applied in
addition to the usual dressing.
The technique has been given somewhat in detail for the
reason that it has been uniformly employed during the entire
ten years, and may have some bearing upon the wound healing.
Wound Healing. Prior to the introduction of rubber gloves,
two and one-half years ago, 96 per cent, of the cases healed by
primary union. After the gloves were used for assistants and
cots or gloves by myself I had a series of 200 cases with but
one suppuration, and this was due to a streptococcus infection
from the skin of the patient, as shown by scrapings taken from
the skin at the time of operation. I believe that these results
in wound healing are in no small part due to the fact that all
bruising of tissue has been carefully everted and operations
have been rapidly performed. In uncomplicated cases the
average time has been twelve to twenty minutes. All bleed-
ing-points have been carefully tied, and the aim has been to
make the field of operation as clearly defined and as dry as a
dissection upon the cadaver.
The buried sutures employed — kangaroo tendon and catgut
— have been prepared by Van Horn & Co., of New York, and
342 COLEY,
during the earlier period were sterilized by boiling in absolute
alcohol under pressure ; during recent years by the cumol
method. These sutures have been subjected to frequent bac-
teriological tests, and have always proved sterile.
Advantages of Absorbable Sutures. The objections that
have been offered from time to time to the use of absorbable
buried sutures rests entirely upon the assumption that it is im-
possible to render such sutures perfectly sterile. That this
assumption is without foundation in fact is conclusively proven
not only by my own experience, but also that of Drs. Bull, De
Garmo, and others who have used these sutures for many years.
It is still further proved by the frequent bacteriological tests,
which invariably have shown these sutures to be sterile. The
ideal buried suture in operations for the radical cure of hernia
is one that, while remaining unabsorbed sufficiently 'long to
secure thorough union of the parts in apposition, becomes ab-
sorbed before it has had time to cause irritation and subsequent
sinus formation. Both catgut and kangaroo tendon may be so
treated with chromic acid as to remain in the tissues any de-
sired length of time before absorption. For hernia operations
I believe that this period should not be more than three to four
weeks.
The disadvantages attending the use of non-absorbable buried
sutures for hernia operations have already been so frequently
pointed out by Dr. Bull and myself that I will not do more
than briefly repeat these important points.
1. Late sinus formation may and frequently does occur with
perfect primary union at the time of operation.
2. The usefulness of a buried suture has been fulfilled at the
end of three to four weeks, after which time, if non-absorbable,
it will cut through the tissues until there is no further tension,
and henceforth remain as a foreign body, capable of causing
much annoyance and predisposing to relapse by sinus forma-
tion and long-continued suppuration.
3. If the object at which we aim is the cure of the patient
we can best obtain this object by the use of absorbable sutures.
I have personally observed these cases in which non-absorbable
RADICAL CURE OF INGUINAL AND FEMORAL HERNIA. 343
sutures were used, with sinus formation more than three years
after operation, although the original wound had healed by-
perfect primary union.
I have observed more than thirty cases of sinus formation
following hernia operations in which silk, silkworm-gut, and
silver-wire had been used for the buried suture. The last case
was a patient operated upon in January, 1900 ; a sinus followed
operation, necessitating his remaining in the hospital until the
following May. In April a portion of the wire was removed,
but the wound did not heal. He left the hospital in May and
made frequent visits to an out-patient department to have the
sinus dressed. It continued to discharge freely until finally, in
December, nearly a year from the time of operation, the re-
mainder of the wire was removed and the sinus finally closed.
In the meantime the rupture had recurred and become several
times its original size. So much suppuration had occurred and
formation of scar tissue that further operation is impossible,
and as the rupture cannot be controlled by a truss, the patient
is practically an invalid. The great majority of the cases with
slowly healing sinuses have been followed by relapse.
This list of unfortunate results following the use of non-
absorbable sutures would seem sufficiently large to demon-
strate the disadvantages of such sutures.
The value of Bassini's operation cannot be judged by the
number of relapses that have occurred in the hands of a few
surgeons, however distinguished, who have operated on but a
comparatively small number of patients. In many of the so-
called Bassini operations the ideal operation could not have
been performed, as proved by the short cicatrix of the wound.
Perfect familiarity with the technique of the operation cannot
be acquired in operating a few times. My experience with
recurrent hernia at the Hospital for Ruptured and Crippled
shows that a large proportion of the patients with relapses
from Bassini's operations were operated upon by surgeons
whose experience was comparatively limited. It is an un-
doubted fact, as our records show, that while operations for the
radical cure of hernia have been steadily and rapidly on the
344 COLEY,
increase for the past ten years, the number of patients with a
recurrence that present themselves at the hospital for trusses
has been just as steadily on the decrease. During the year
1 89 1 sixty-four patients with recurrent hernia applied for treat-
ment at the Hospital for Ruptured and Crippled, while during
the past year (1900) but twenty-six applied. This shows more
conclusively than anything else the vast improvement in present
methods and technique over those in vogue a decade ago ; that
this fact is still further confirmed by the paper of Delbet on
"The Remote Results of the Radical Cure of Hernia."^ Dur-
ing the first six months of the year 1900 he states that in the
"Service des Bandages" in Paris only seven patients with a
recurrent hernia represented themselves. The author concludes
that " if the enormous number of operations performed for the
radical cure of hernia at the Paris Hospital is taken into con-
sideration, the small number of recurrent herniae observed in
institutions for the supply of trusses is a sure indication that
operations for the cure of this affliction are really radical."
Cases of Unusual Interest. Hernia of the CoBciim and
Sigmoid Flexure. I have operated upon upward of thirty cases
of hernia of the sigmoid or csecum and appendix. A consid-
erable number of these have been cases of sliding hernia, or
hernie par glissement, as designated by the French authors. In
these the usual peritoneal sac is imperfect, generally lacking in
its posterior aspect. This condition, while much more common
in the csecum, I have occasionally observed in hernia of the
sigmoid flexure. The difficulty of operating upon this class of
slipped or sliding hernia of the caecum and sigmoid has been
recently pointed out by Dr. Weir. Clinically this condition can
be frequently diagnosticated by the fact that attempts to replace
the protruding bowel into the abdominal cavity accomplish
little. While a certain portion may be reduced, a considerable
portion is always left behind, and this can usually be differ-
entiated from adherent omentum.
In a number of cases which I have observed at the Hospital
' Bulletins et Mdmoires de la Societc de Cliir., 1900, No. 28.
RADICAL CURE OF INGUINAL AND FEMORAL HERNIA. 345
for Ruptured and Crippled the diagnosis was made before oper-
ation on basis of this finding.
According to Dr. Weir, the sliding hernise are more frequent
in the left side of males, and in middle and advanced life. The
usual history prior to operation is that of a hernia, at first redu-
cible, but not always easy to control with a truss. This con-
dition soon passes into one of permanent irreducibility.
My own experience does not confirm the opinion of Dr. Weir,
that the sliding herniae are more common on the left than on
the right side, nor do I believe that they are more common in
males in middle or advanced life — in fact, very few statistics
upon operations for hernia in children, with sufficiently full
details for comparison, are available. An analysis of 775 cases
of hernia in children operated upon at the Hospital for Rup-
tured and Crippled shows a comparatively large number of
caical hernitTe, a considerable proportion of which are of the
variety described by Dr. Weir.
My own personal statistics show a greater proportion of slid-
ing hernia in children than in adults ; and I believe that when
statistics are sufficiently complete to make a fair comparison
possible we shall find this to be true in general.
The operative treatment of this form of hernia is by no means
easy. Weir states that in his earlier cases he attempted to push
up the bowel toward the internal ring, and to hold it there by
sutures carried from below the intestine to the side of the ring
or through the abdominal wall. This operation proved a failure.
In 2 more recent cases he separated the bowel from its poste-
rior attachments and then made a flap of the peritoneal portion
of the sac, which was turned backward and sutured behind the
gut as far as practicable. These 2 cases were well eight months
after operation.
In my own cases I have followed the plan of separating the
caecum and bowel sufficiently high up to permit of complete
reduction. The peritoneal opening is then sutured with cat-
gut, and the abdominal wound is closed in three layers, as in
Bassini's operation, without transplantation of the cord. In 2
cases only has relapse occurred.
346 CO LEY,
Ingiimal Hernia Associated %vith Undescended Testes. I have
operated upon 30 cases of undescended or partially descended
testes associated with hernia. Fourteen of these cases were
between ten and fourteen years. The testis was not removed
in a single case, and I believe that in practically all cases of
undescended testis associated with hernia in which operation is
indicated it will be found possible to bring the testis outside of
the external ring. The canal can then be closed by Bassini's
method, or by allowing the cord to come out of the lower angle
of the wound, without transplantation. This latter method per-
mits the testis to be brought down one-half to three-quarters of
an inch lower than when the cord is transplanted.
In most of these cases the testis was considerably smaller
than that on the opposite side. In some of my earlier cases,
operated upon between 1891 and 1895, I attempted to keep the
testis down by anchoring it in the scrotum, either to the scrotum
or to a wire frame outside of the scrotum. In most of these
cases the testis retracted to a position just outside the external
ring, and, as there seemed to be very little gained by the various
methods of anchoring, I soon gave them up. With one excep-
tion all my cases were operated by Bassini's method. The
results, as far as the cure of the hernia is concerned, have been
perfect in every instance. I believe that operation is rarely
indicated as a routine measure before the age of ten and twelve
years, for the reason that in many cases the testis descends into
the scrotum or below the external ring about the age of
puberty. The accompanying rupture is usually small, has little
tendency to become strangulated, and maybe easily retained by
a light spring truss, the pad of which rests above the testis.
Ingidno-perineal Hernia Associated with Maldescent of the
Testis. I have observed 6 cases of testis in the perineum, and
in 4 of these there was an accompanying well-developed hernia,
the latter following the course of the testis, and appearing in
the perineum rather than the scrotum. In one of these cases,
already reported, in which the hernia was the size of a cocoa-
nut and the testis very small and ill-developed, the testis,
together with the entire pouch, was removed and the canal
RADICAL CURE OF INGUINAL AND FEMORAL HERNIA. 347
closed in three layers. The patient remained well for about
three years, and death resulted from drowning. In the other 3
cases the testis was apparently full developed, and I was able to
preserve a sufficient amount of peritoneum to make a perfect
tunica vaginalis. I then formed a new pouch with the finger in
the hitherto empty scrotum, into which the testis and its new
tunica were transplanted.
The patients all made an excellent recovery and have remained
free from recurrence up to the present time, one to three years
after operation.
Properito7ieal, or Interstitial Hernia. — Four cases were inter-
stitial or properitoneal hernia. Interstitial hernia is generally
associated with undescended testis. Of 42 cases of interstitial
hernia collected by Langdon, there were only two instances
in which the testes were normally developed in the scrotum.
The position of the testis varied between wide limits. In 2 cases
it was high up in the scrotum ; in two others, just outside the
external ring ; in 26 it was situated in the canal. The relative
frequency of interstitial hernia, as estimated by Langdon, is i in
IIOO cases. Of my own cases, the one most worthy of note
was a properitoneal Richter hernia, occurring in a boy, aged fif-
teen years. Operation was performed about fifteen hours after
strangulation. A loop of small intestine was found tightly
constricted by the neck of the sac at the internal ring, includ-
ing about seven-eighths of the lumen of the bowel. The patient
made an excellent recovery.
Radical Cjtre of Inguinal Hernia in the Female. Up to the
present time I have operated upon 155 cases of inguinal
hernia in the female without a single relapse. The method
employed I have recently described in detail,^ and will
merely say that the technique is practically the same as in
the operation for inguinal hernia in the male, with the excep-
tion that the round ligament, after having been carefully dis-
sected from the sac, is allowed to drop back into the lower
angle of the wound. The canal is closed in two layers, pre-
* Annals of Surgery, December, 1900.
348 COLEY,
cisely the same as in the male. The round ligament as it
approaches the pubic bone occupies so little space that it
requires a much smaller opening than the cord in the male ;
and my own results would seem to show that there is no
necessity for transplanting it, as has been advocated by Kelly
and others. The dissection of the sac from the round liga-
ment, while somewhat more difficult than dissection of the
sac from the cord in the male, can, I believe, always be accom-
plished with comparative ease. And therefore I do not think
that the excision of the round ligament with the sac, as advo-
cated by Championniere, is ever called for. The neck of the
sac can always be easily reached, and the ligature or suture
placed well beyond the sac, where it widens out into the
general peritoneal cavity, both in the male and the female,
without cutting the internal oblique muscle. The cutting
of the internal oblique greatly weakens the canal, I am con-
vinced, and increases the chances of relapse. Up to the
present time but few statistics are available bearing upon
the relative results of the various methods for the cure
of inguinal hernia in the female. Among the 459 cases
of hernia operated upon at the Johns Hopkins Hospital, and
reported by Bloodgood, only 39 were of this variety. The
round ligament was excised in 20 cases, and the internal oblique
muscle divided and transplanted. In 6 cases the ligament
was excised, but the internal oblique not divided. In 3 the
round ligament was not disturbed, but the internal oblique was
divided and transplanted. In 5 cases the round ligament was
left undisturbed and the internal oblique not divided. Perfect
results were noted in 21 cases, in 6 of which the patient had
remained well from three to eight years. In one case there
was a recurrence.
Championniere has recently reported 70 cases with 3 relapses.
The ages of my personal cases ranged between four and
seventy years. The average time they were confined to bed
was ten days. Most of them were allowed to go home at
the end of two weeks. Thirteen of the patients have been
traced.
RADICAL CURE OF INGUINAL AND FEMORAL HERNIA. 349
Femoral Hernia. Although a large number of methods for
the radical cure of femoral hernia have been proposed from
time to time, it has been impossible to judge of their relative
value except on theoretical grounds, for the reason that, with
the single exception of Bassini's statistics for femoral hernia,
very few cases have been reported or traced for any length of
time. Bassini published a series of 53 cases operated upon by
his own method, with no mortality and without a single relapse
in 41 cases traced from one to nine years.
Although Bacon, in his recent paper/ attempts to show
that Bassini's method is mechanically defective, these practical
results go far toward outweighing any theoretical shortcomings.
Personally, I have operated upon 54 cases of femoral hernia
during the past nine years, and thus far but one relapse has
been observed. Sixteen of these cases were operated upon by
Bassini's method, all the others by the so-called purse-string
method originally proposed, I believe, by Gushing, of Boston.
The technique in brief is, first, to thoroughly free the sac well
beyond the neck ; high ligation of the sac and closure of the
canal by means of a purse-string suture of chromicized kangaroo
tendon. The suture is introduced through Poupart's ligament
or the inner portion of the roof of the canal, or crural arch,
from where it passes downward into the pectineal muscle or
floor of the canal, outward through the fascia lata overlying the
femoral vein, and upward through Poupart's ligament or roof
of the canal, emerging about three-fourths of an inch from the
point of introduction. On tying the suture, the floor of the
canal is brought into apposition with the roof, and the femoral
opening is completely obliterated. The superficial fascia may
then be closed with catgut or fine tendon, and the skin either
with catgut or silk. This method of closing the femoral canal
is considerably simpler than Bassini's, and from the results that
I have obtained I am inclined to give it the preference, except
possibly in hernia with a very large opening. In 38 cases
operated upon by this method not a single relapse has been
' Yale Medical Journal, January, 1901.
350 COLEY,
observed. The only recurrence that took place in the 54
cases occurred in a case operated upon by Bassini's method, a
woman, aged thirty-five years, with femoral hernia the size of
an egg. Operation was performed in March, 1896. Curiously
enough, this is the only case of femoral hernia in which sup-
puration occurred, which delayed the wound healing four
weeks. A very slight relapse took place a year and a half
later. I personally examined the patient two weeks ago, five
years after operation, and, although she does not wear a truss,
scarcely more than an exaggerated impulse could be detected.
In all operations for femoral hernia I believe it to be most
important to thoroughly free the canal from all extraperitoneal
fat. As regards the period of convalescence, I have kept
patients in the hospital for a little shorter time than in inguinal
hernia, allowing them to sit up on the tenth day and to go
home at the end of the twelfth or fourteenth day. No truss has
been worn after operation in any case.
A Study of Relapsed Cases. An analysis of the relapsed
cases in my series is of interest, inasmuch as in nearly every
instance a sufficient cause for the relapse can be found. Of
776 cases of inguinal hernia operated upon by Bassini's method,
with kangaroo tendon for the buried sutures, six relapses have
been observed. These occurred in the following cases.
Case I. — Male, aged thirty-five years, with large inguino-perineal
hernia. Operation was performed on July 9, 1896. The testis was
preserved, but was not transplanted into the scrotum, as in my two
later cases of hernia of this variety. The wound was closed by Bas-
sini's method and healed by primary union. The patient was very
stout, and had much adipose tissue. In addition he was a butcher,
and resumed work immediately after leaving the hospital and did
heavy lifting. The hernia recurred four months later, being the size
of a pigeon's egg.
Case II. — Male, aged twenty-seven years, with large, irreducible
omental scrotal hernia of eight years' duration. Operation was per-
formed July I, 1897, Bassini's method being employed. The wound
healed by primary union. Twenty months after operation there was
a slight weakness in the canal, and a truss was advised, though the
RADICAL CURE OF INGUINAL AND FEMORAL HERNIA. 35I
rupture had never come down, and one might well hesitate to call it
a relapse.
Case III. — Male, aged twenty-five years, with large scrotal, right
inguinal hernia, was operated upon in fall of 1894 by Bassini's method.
He remained perfectly well, doing heavy lifting without support, and
was in a cavalry regiment in the Cuban war, doing hard riding. He
contracted typhoid fever, and during the illness resulting his weight
fell from 140 to 109 pounds. Shortly after convalescence, before he
regained his lost weight, when attempting to head a barrel weighing
500 pounds, he felt something give way in the old cicatrix, and shortly
afterward noticed a small bulging. Examination the following year
showed a slight recurrence in the region of the internal ring. I re-
operated upon him in April, 1901, and a description of the condition
found will be given later.
Case IV. — P. M., male, aged twenty years, was operated upon in
1893 for a right inguinal hernia. The wound healed by primary
union and he remained well until two years Idter, when he received a
severe kick in the groin during a fight. A very slight relapse occurred
in the canal at the site of the internal ring. A truss was applied, and
little more than exaggerated impulse has been noted since.
Case V. — O. S., male, aged twenty-three years; operated upon
September 7, 1898, for a large, reducible inguinal hernia. Severe
staphylococcus suppuration extending to the deeper layers occurred.
The patient remained well until eighteen months later, when, on lift-
ing a barrel of potatoes, he felt something give way, and a small pro-
trusion was observed in the canal.
Case VI. — J. W., male, aged eighteen years. Operation was done
in 1893 fo'" ^ i"'g^t inguinal hernia. The patient remained well for
six years, at the end of which time a slight weakness was observed in
the canal, and a truss applied.
In addition to these 6 cases there has been i other relapse in
a case operated upon by the house surgeon in my service at the
Post-Graduate Hospital. The patient was a boy, aged four
years. Very severe and prolonged deep suppuration followed
operation, and the wound was four months in healing. Relapse
occurred six months after operation.
In still another case, in which Bassini's operation with a dif-
ferent technique was employed, relapse occurred. This was the
352 COLEY,
first time I attempted to perform Bassini's method, and the
operation was very imperfectly done. Silk was used for the
buried sutures, the hernia was very large, and the operation
prolonged. Deep suppuration followed, with extrusion of
nearly all the buried sutures. Relapse followed three months
afterward.
Eliminating the last 2 cases, inasmuch as they do not prop-
erly belong to the main series of cases operated upon by a uni-
form technique, with buried absorbable sutures, we have but 6
relapses in 773 cases.
Much time and effort have been spent in tracing these cases to
final results.
Eighteen cases of inguinal hernia in the male were operated
upon without transplantation of the cord. These were nearly
all early cases, operated upon between the years 1891 and 1893.
In 6 of these cases relapse followed. It is to be noted, how-
ever, that two of these cases were csecal hernia.
Direct Hernia. I operated upon 1 1 direct hernia in seven
individuals, in 4 cases the hernia being double. Bassini's
method was employed in all except i, and in this the cord was
not transplanted.
Relapsed Cases Cured by Second Operation. The following cases
have some bearing upon the question of operating upon cases
that have once relapsed :
Case I. — V. S., aged nine years. Operation by Czerny's method,
with silk, January, 1892. The wound healed by primary union, but
in a {t'f^ weeks a small sinus formed, and some of the silk sutures came
out. The hernia relapsed in about four months. 1 again operated by
Bassini's method in July, 1892, using kangaroo tendon for the buried
sutures. The patient is at present free from recurrence, nearly nine
years later.
Case II. — F. H., aged ten years, was operated upon February 10,
1892, by Czerny's method, with chromicized catgut for the buried
sutures. The hernia relapsed in three years. In July, 1895, I again
operated ; this time by Bassini's method, with kangaroo tendon for
the buried sutures, and the hernia was perfectly sound in October,
1900, more than five years later.
RADICAL CURE OF INGUINAL AND FEMORAL HERNIA. 353
Case III. — A. B., male, aged twelve years. He had been operated
upon by Dr. Bull by Czerny's method, non-chromicized catgut for a
double inguinal hernia, February 4, 1893. The hernia relapsed on
both sides within two months after operation. On April 11, 1893, ^
operated on both sides by Bassini's method, with kangaroo tendon
sutures. The patient was perfectly sound when last observed, April
22, 1899, or six years after the secondary operation.
Case IV. — W. V. S., aged forty years, with double inguinal hernia.
This case is of very great interest, inasmuch as the operations were
performed in August, 1891, nearly ten years ago. I used Bassini's
method on the right side and Czerny's on the left. Both sides re-
mained firm until the fall of 1900, or nine years after operation, when
the left side recurred in the canal. I operated for the recurrence one
week ago, this time by Bassini's method. The right side remains per-
fectly sound.
I have operated upon a number of other patients for relapse
following other methods of operation, but the cases are more
recent, and hence of less interest. The only operation for
relapse foUovi^ing Bassini's method that I have performed was
done a week ago upon the patient operated upon seven years
ago and in whom the relapse was due to heavy lifting after
enormous loss of weight from an attack of typhoid fever. In
this case I found the union of the aponeurosis absolutely firm ;
the recurrence had taken place at the internal ring, and consisted
merely of a dilatation of the space left for the cord to emerge.
There was no sac, but a bulging of the peritoneum into the
space referred to, and dissecting ofif for a small area the apo-
neurosis from the underlying internal oblique muscle. The cord
was rather adherent to the aponeurosis and oblique muscle, but
was separated, and Bassini's operation was again performed,
leaving a very normal opening for the cord at the internal ring.
The superiority of Bassini's method is further confirmed by
the splendid results obtained at the clinic of Professor Carle, as
reported by Galeazzi.'
' " Risultati definitive nella cura operativa del I'ernia inguinale," by Galeazzi. Estratto
della clin. Chir., 1899, No. 6.
Am Surg 23
354 COLEY,
During the ten years between 1889 and 1899, 1400 operations
for the radical cure of hernia were performed at the clinic upon
1285 patients, with but two deaths, and one of these occurred
as a result of pneumonia on the seventh day after operation.
Bassini's method was employed in 11 20 of these 1400 opera-
tions ; Kocher's in the remaining 280. Efforts were made to
trace the cases, and it was ascertained that in 840, in which
upward of two years had passed between operation and exam-
ination, 792, or 94.29 per cent., remained perfectly sound ; while
48, or 5.71 per cent., showed a recurrence.
Galeazzi collected a further series of 1334 cases of hernia
operated upon according to Bassini by surgeons outside of Italy,
which showed but 2.16 per cent, of relapses.
The importance of primary wound-healing in effecting a per-
manent cure is well illustrated by the cases observed at Carle's
clinic. Of 128 cases of secondary wound-healing 10, or 7.9
per cent., relapsed ; and of these relapse occurred during the
first year in 7 ; during the second year in 2, and after two years
in but I, thus demonstrating that relapse is far more likely to
occur during the first year after operation than later.
In 84 cases of voluminous hernia, Galeazzi states there were
but 2 relapses. At the same time he points out the danger of
operating upon very large irreducible herniae.
Galeazzi considers Bassini's method more logical, more sur-
gical, and more secure than Kocher's, and believes that the
superiority of the method is especially shown in cases in which
the canal is not straight, since the obliquity of the canal favors
its closure at the moment when the intra-abdominal pressure is
exerted or increased, and to this fact he ascribes the excellent
results that have been obtained by Bassini's method.
Dr. De Garmo, of New York, has operated upon 612 cases,
with but 8 relapses.
The large statistics of Dr. Bull, though not published up to
date, still further confirm the superiority of this method.
During the period from 1891 to 1901 I have operated upon
845 cases of inguinal hernia and femoral hernia. Of these 791
were operations for inguinal hernia, 773 of which were operated
RADICAL CURE OF INGUINAL AND FEMORAL HERNIA. 355
upon by Bassini's method, with the substitution of silk by kan-
garoo tendon for the buried sutures ; 54 were operations for
femoral hernia, with but i relapse.
Five hundred cases of inguinal hernia, operated upon by
Bassini's method, were traced from one to nine years, with 6
relapses. Of 155 cases of inguinal herniae in the female, 84
were traced from one to eight years after operation, without a
single relapse.
Of the 54 cases of femoral hernia, 31 were well from one to
nine years after operation.
Of the inguinal herniae operated upon by Bassini's method,
10 were well from eight to nine years after operation ; 13, from
seven to eight ; 23, from six to seven ; 26, from five to six ; 54,
from four to five ; 89, from three to four ; 104, from two to three ;
178, from one to two.
356 DISCUSSION.
DISCUSSION.
Dr. J. Collins Warren, of Boston.
I wish to thank Dr. Coley for his very valuable work in placing his
operations on a sound basis, as it is a standard which we now can go
by. We all concede the operation to be a success, and nearly all the
cases are cured, there being very little difficulty in getting healing by
first intention. There remains, however, certain details of interest,
and one is age. The question of operation in infancy is an interest-
ing one, and what shall be our decision in any given case is an
important one. The tendency is to operate much more now than
formerly ; but sometimes even up to the age of twenty-one we may get
a radical cure by a truss. I have seen such cases which have gotten
entirely well, and have also seen some in young men who have grown
up with a truss, and then had to be operated upon afterward. I had
to operate recently on a young man whom I had treated in childhood
with a truss with apparent success. Athletic exercises are very hard
on the inguinal canal. As an example of what a tremendous strain
may be borne I might mention the case of an athlete upon whom I
operated several years ago. Seeing a man about to drop a trunk he
rushed to his aid, seized the trunk and saved it, but ruptured himself
on the sound side without reproducing his old hernia on the other
side.
I recall the case of a grocer upon whom I operated several years
ago, who told me that he had had no recurrence, although he was in
the habit of carrying several barrels of flour daily up two flights of
stairs.
Then as to the other extreme of life. I have a man, aged seventy
years, on whom I would like to operate, but question the advisability
of attempting relief in this way unless there be urgent need.
As to sepsis, I believe we all have had more or less of this in the
beginning, but very much less now than in the past. I do not attribute
this so much to the use of gloves as to the final preparation of the
patient immediately before the operation, which is most important.
As to absorbable sutures, the question is, what is and what is not an
absorbable suture. Certain forms of chromicized animal suture have
to be removed after long intervals, and I do not think that chromi-
RADICAL CURE OF INGUINAL AND FEMORAL HERNIA. 357
cized absorbable sutures are any more absorbable than silk. Person-
ally I get better results with silk which may be boiled five minutes
before operation. I do not approve of any method which involves
metallic sutures. I do not regard silk in the nonabsorbable class.
Dr. W. S. Halsted, of Baltimore.
I consider this paper justifies the great credit Bassini deserves for
his operation. I have not been in the habit of dividing the internal
oblique muscle during the last few years, and yet our results are just as
good as could be obtained. I believe the tendency should be to
simplify the operation. The recurrences that we have had were in
cases where the veins had not been removed. It seems to be a very
rational procedure, and we have not had a single recurrence when
they have been removed. Lately we have not been transplanting the
cord, and we no longer get atrophy of the testicle after removing the
veins. Of course we leave the vas deferens in place.
As to silver wire, we have been very much interested in it ever since
we have used it, because we cannot see such results as others get. We
have been over all of our cases this spring, and we find we have closed
up 520 cases with silver wire out of 780 cases operated on. Our
assistants report that they do not see quite the same healing of the
skin. 2614 sutures were used in the cases reported, and there were
25 cases of suppuration, which is a larger percentage than that reported
by Dr. Coley. Where there is a hemorrhage and we let out any
blood we call it a suppuration, and if we only have one drop of pus
we call it the same. We have removed from suppurating wounds two
sutures, and these were in two cases. Of sutures removed after leaving
the hospital there were three ; sutures removed for secondary stitch
abscess in which the wound had healed primarily, none; sutures re-
moved for pain, one, and this was in the case of a man who was
neurasthenic ; cases of secondary stitch abscess after leaving the
hospital, one, but no suture was removed, and the abscess healed. In
appendicitis wire was used in 227 cases, necessitating nearly 1000
sutures. In 16 cases, which include all abscess cases, there was some
suppuration about the packing, but stitches were only removed in four
cases ; sutures removed after leaving the hospital, one ; sutures re-
moved for pain, five, but we are quite sure that they had nothing to
do with the pain. 1 do not know of a single case where the removal
of the suture relieved the pain.
358 RADICAL CURE OF INGUINAL AND FEMORAL HERNIA.
Dr. Coley. As to the age question, raised by Dr. Warren, I would
state that I have operated on people over seventy years of age, but I
do not think it should be a routine measure above fifty or sixty.
As to the question of absorbable sutures I have not much to add.
As to silk, in the cases of sinus formation that I have observed silk
has been the least offender. It is true that kangaroo tendon or catgut
may be so chromicized as to remain unabsorbed for a long time,
but that would put it in the class that I call non-absorbable sutures.
Concerning silver wire, a considerable number of these cases of sinus
formation have been where wire was used. In a certain proportion
the wound had healed by primary union.
It is not always the hospital in which the operation was performed,
or the surgeon who operated on them, that see the returned cases with
sinuses. Most of the cases that I have observed had not been back to
the surgeon who operated, and he was therefore not in a position to
state that a good result did not follow the original operation.
Dr. Halsted himself reports enough cases, I think, to justify us in
abandoning silver wire as a buried suture in hernia operations, if we
can show, as I think we have, that equally as good or better results as
regards radical cure can be obtained with absorbable sutures.
TREATMENT OF AORTIC ANEURISMS BY MEANS
OF SILVER WIRE AND ELECTRICITY;
WITH REPORT OF CASES.
By LEONARD FREEMAN, M.D.,
DENVER, COL.
The literature of this subject has been so thoroughly col-
lected and studied by D. D. Stewart and Guy L. Hunner. in
their recent elaborate papers,' that it is unnecessary for me to
go over the ground again. I shall merely mention a few promi-
nent points :
The method of treating aneurisms of the aorta by means of
a fine wire introduced through a hollow needle and coiled
within the sac was first suggested and carried out, in 1864,
by Charles H. Moore, of the Middlesex Hospital. Corradi, in
1879, added much to the effectiveness of the procedure by
passing a strong galvanic current through the wire, thus pro-
moting more rapid and firm coagulation. It has hence been
designated the " Moore-Corradi Operation." D. D. Stewart, of
Philadelphia, has done more than anyone else to bring the
operation into prominence, perfect its technique, and empha-
size its possibilities.
There have been reported, according to Hunner, of Johns
Hopkins, 14 cases in which wire alone was used, with 3 recov-
eries, although one patient subsequently died from rupture
of the aorta below the tumor, and 23 cases in which both wire
and galvanism were employed, with 4 recoveries. In all 37
' Hunner, Johns Hopkins Hospital Bulletin, November, 1900; Stewart. American
Journal of the Medical Sciences, October, 1892; Ibid., August, 1896; Philadelphia
Medical Journal, November 12, 189S.
360 FREEMAN,
cases, with 7 recoveries. There have also been a number of
encouraging improvements.
Apparently this is not a brilliant showing, but it must be
borne in mind that many of the aneurisms were extremely
unfavorable for operation. In some instances the sac was fusi-
form, or had several compartments, or was on the point of
bursting; while in others the patients were nearly dead from
exhaustion or from pressure upon the trachea ; and occasionally
a poor technique seems to have been directly at fault. Failure,
under such circumstances, cannot excite surprise, and it must
not be lost sight of that no other treatment can furnish results
at all comparable to these.
To obtain the best results, it seems evident that the cases
should be carefully selected. The aneurism should be sac-
culated, not fusiform, without too large an opening, and with
but one compartment. It should not have progressed too far
toward rupture, and the patient should have sufficient vitality
to enable him to live through the tedious process of cure. It
is scarcely necessary to state that the operation is practically
confined to aneurisms not amenable to other surgical procedures
— /. e., aneurisms of the abdominal aorta, the thoracic aorta, the
innominate artery, etc., the first named requiring a preliminary
coeliotomy.
An accurate diagnosis is of the utmost importance, but in
spite of the greatest care, mistakes are apt to occur. We will
hope, however, that when the operation comes into more gen-
eral use, better methods of investigation will arise. Perhaps
the X-ray may be of service, as insisted upon by Dudley Tait,
of San Francisco.
In addition to reporting two cases of my own, my object is
to discuss several points pertaining to the technique, which,
according to Stewart, is briefly as follows : Asepsis, local anaes-
thesia, insertion into the aneurism of an insulated hollow
needle through which is introduced silver wire (about No. 27).
It must be well drawn and wound on a spool, to increase its
tendency to coil, and from three to twenty feet in length,
according to the size of the cavity. The wire is then attached
TREATMENT OF AOKTIC ANEURISMS. 36 1
to the positive pole of a galvanic battery, the negative electrode,
large and well moistened, being applied to the back, and a
current of 70 to 80 ma. passed for from half an hour to an hour
and a half. The wire is then cut close to the skin and sunk
beneath the surface.
Let us consider in detail some of the questions involved :
Character of the Wire. Most operators agree that silver
wire is preferable to any other. It is easily obtained, inexpen-
sive, is a good transmitter, and becomes sufficiently corroded by
the passage of the electric current to insure adhesion of the clot.
Steel is said to be too brittle, and soft iron too easily disinte-
grated. The wire should be fine, about No. 27, because fine
wire coils more readily and offers less resistance to electricity
and to contraction of the sac. Silver wire varies much in elas-
ticity, according to the amount of copper which it contains and
the degree to which it is drawn. Hunfter lays great stress
upon the use of highly-drawn wire (from No. 8 to No. 27), con-
taining seventy-five parts of copper to the thousand, making it
so hard and springy that it readily retains the coil imparted to
it. Stewart also insists upon the use of wire which has been
drawn, and both he and Hunner strongly advise winding the
wire upon a spool before inserting it. These ideas are founded
upon the manner in which various kinds of wire deport them-
selves when introduced into glass flasks. They claim that much
can be learned in this way regardmg the behavior of wire in an
aneurism, and that it is better no one should operate upon the
living until numerous experiments of this kind have been
made.
Hunner, in his beautifully illustrated article, shows how ordi-
nary undrawn silver wire arranges itself in large circles around
the periphery of a flask without filling the centre ; while his
highly-drawn, elastic wire coils itself in the middle of the
receptacle. (These experiments were made by Hunner and
Finney in the laboratory of the Johns Hopkins Hospital.)
It is somewhat questionable, however, whether it is advisable
to have most of the wire in the centre and comparatively little
in contact with the walls of an aneurism. The firmness of a
362 FREEMAN,
clot, its Stability, and its capacity for organization must depend
somewhat upon the support derived from mural implantation.
A clot suspended in the centre of the sac would be of little
use, however satisfactory its consistency. In addition, we must
not forget that an aneurism cures itself by the deposition of
clots about its circumference, and that the electrolytic effect of
galvanism upon the sac, as demonstrated by Macewen, promotes
the accumulation of leukocytes and the formation of firm,
white, readily organizing coagula.
But, aside from these more or less theoretical considerations,
it occurred to me that glass flasks do not represent actual con-
ditions,and that we can draw no reliable conclusions from their
employment. In repeating Hunner's experiments, which I did
with wire obtained directly from him, as well as with ordinary
silver wire, both drawn and undrawn, I found that the strands
slipped easily about within the smooth, hard, glass-lined cavity,
and arranged themselves always in a definite manner, as he has
described. The inside of an aneurism, however, is not hard
and smooth ; it is often irregular and coated with more or less
rough layers of clot, so that the wire would easily catch and be
deflected from its natural course. Also, the coils could not
rotate within the cavity and adjust themselves when pushed
upon by the entrance of a fresh portion, as occurs in a flask.
In order to represent more accurately the conditions as they
really exist, I obtained a large Colorado turnip, the size and
shape of a flask of 500 c.c. This I hollowed out through an
opening large enough to observe what took place within.
The walls were of the consistency of an old, firm clot, and of
about the right irregularity and roughness. After running a
hollow needle through the side of tiiis "aneurism," I inserted
various kinds of wire. My observations convinced me that
the glass-flask method had led to erroneous and misleading
conclusions. Ordinary undrawn silver wire, under these new
conditions, coiled itself backward and forward and around
through the cavity, not only covering the walls to a satisfactory
extent, but filling the centre also — totally different from its con-
duct in a flask. Even wire not previously coiled did almost if
TREATMENT OF AORTIC ANEURISMS. 363
not quite as well in this regard. The stiff, springy wire ob-
tained from Dr. Hunner formed a good network also, but
not so good as the ordinary wire. The meshes were not so
evenly distributed over the walls and centre ; and when the
wire had been wound upon a large spool it was still less
effective, quite large, open spaces being left within the curl-like
rings.
When the needle was directed away from the opening there was
little or no tendency on the part of the ordinary wire to escape
through it ; but a coil or an end of the Hunner wire would often
spring suddenly through the hole, like a jack-in-a-box. I feel
that a real danger lurks in these sudden movements, from dis-
lodgement of clots, penetration of the aorta, etc. The phenome-
non was, of course, still more marked when the needle was
directed toward the opening. Through a trap-door in the
turnip I was able to extract the coils without disarranging them.
I observed that a coil of ordinary soft wire could easily be
squeezed together in the hand, and that it remained as it was
moulded, while a coil of drawn and alloyed wire (Hunner) was
so springy that it resumed its original shape as soon as the
pressure was removed.
These experiments convinced me that Hunner and others
are mistaken in their deductions. Instead of hard, elastic wire
being superior to the ordinary soft variety, the advantage lies
just the other way. The elastic wire really possesses certain
disadvantages — it kinks in a more anno)'ing manner and breaks
more readily; it does not coil so satisfactorily within an
aneurism ; it is more liable to protrude, sometimes with force,
through the aortic opening; its sudden movements during
introduction may dislodge dangerous clots ; and its inherent
springiness would tend to prevent contraction of the sac wall,
although I do not lay so much stress upon this as do some.
Soft, unalloyed silver wire has another advantage over the
harder variety in that it more rapidly loses in size under the
influence of the electric current, and becomes much rougher
and more brittle. I found this difference quite marked in a
seance of but twenty minutes. Wire thus acted upon breaks
364 FREEMAN,
and crumbles to pieces readily, and can offer no appreciable
resistance to contraction.
In the course of my experiments I noticed another point of
some importance. If the canula is inserted too far into the
sac, as we are apt to insert it, the wire has a strong tendency
to curl up against the further wall, leaving a more or less clear
space surrounding the place of entrance — a spot which often
needs strengthening more than others. This may be avoided
by just penetrating the aneurism with the needle, and no more.
Quantity of Wire to Be Used. Stewart, Hunner. and
others confidently assume that it is far better to employ a small
amount of wire (from three to ten feet, or, at most, twenty feet)
than a large amount.
They are so sure of this that they attribute some of the fail-
ures which have occurred to a disregard of this principle. Their
theory is based upon the following considerations: (i) Large
amounts of wire are unnecessary, smaller pieces producing clots
which are just as satisfactory. (2) Much wire tends to prevent
contraction of the sac wall, upon which depends the cure. (3)
The reported recoveries were obtained with small amounts of
wire.
At first sight these points appear convincing, but upon closer
inspection it develops that both reasoning and conclusion are
open to question.
It seems sufficiently evident that the greater the quantity of
wire used the more certainly and quickly will a clot form, and
the more firm and lasting will it be, lodged, as it is, among the
meshes of the wire ; in fact, if every portion of the sac could
be filled completely with wire there would be no room for
blood at all, and the aneurism as such would cease to exist.
Aneurisms are definitely cured by the gradual replacement
of coagula by fibrous tissue, which slowly but firmly contracts.
The contractile power of such a mass is certainly considerable,
as is seen in scar-tissue in other portions of the body, and is not
to be seriously impeded by the presence of a more or less loose
coil of fine silver wire, especially if the wire be soft and devoid
of spring. This can be more clearly appreciated after crushing
TREATMENT OF AORTIC ANEURISMS. 365
such a coil in the hand, Hunner and Stewart admit the power
of this contractile force when they assert that it is dangerous
to use steel wire, because of the likelihood of its breaking and
penetrating the sac wall. If steel wire can be broken, soft silver
wire can certainly be easily bent into a small compass.
But even admitting that contraction would be to a certain ex-
tent impeded, it is hard to see what actual harm would be done
in the presence of a firm, well-organized clot. To be sure, con-
traction would sooner reach its limit, a larger bunch of tissue
remaining; but as long as this consisted of closely coiled wire,
connective tissue and fibrin, no objection could be made to its
mere presence. It can here be clearly appreciated that soft,
undrawn wire would possess a decided advantage over that
which is hard and springy, as the latter would cause a continu-
ous centrifugal pressure.
It is true that, the reported cures have been obtained in cases
where small amounts of wire were used ; but this fact is mis-
leading, as is shown by a glance at the records as given by Hun-
ner himself. According to these, wiring has been resorted to
thirty-seven times, much wire being employed in but seven in-
stances, i. e., 78 feet, 75 feet (in two sittings), 32 feet, 33 feet,
225 feet, 150 feet, and 32 feet (in three sittings). It is, however,
questionable whether such lengths as 32 and 33 feet should be
considered as " much" wire when we remember that both Stewart
and Hunner recommend as high as 20 feet under certain circum-
stances. The figures would then stand 33 to 4. For the sake of
argument, however, we shall assume that much wire has been
used in 7 cases and a small amount in 30. But 4 of these 7 cases
must be excluded because of features rendering their considera-
tion absolutely unfair. They are as follows :
Moore's case (78 feet) died of sepsis.
Cayley's case (75 feet), two sacs, with a very large opening
into the main vessel.
White and Gould's case (32 feet), two sacs, fusiform aneurism ;
death from sloughing due to pressure from without.
Abbe's case (150 feet), reversed current in middle of sitting,
and probably softened clot already formed.
366 FREEMAN,
This leaves but 3 cases, one in which 33 feet were used, one
32 feet, and one 225 feet — /, e.:
Hulke's case (33 feet), "desperate condition," wire did not
fill entire sac, which continued to expand in empty portion. If
this case shows anything, it is that not enough wire was used.
Finney's case (32 feet, in three sittings). No autopsy, and
hence we know nothing of the real condition of things within.
Roosevelt's case (225 feet) improved, the tumor becoming
firmer. Died on twenty-second day, probably of embolism.
It is thus seen that a really large amount of wire (225 feet) has
been used in but one case which can be called at all favorable, and
in this the patient lived twenty-two days, finally dying of what
appeared to be embolism — an accidental complication. In the
meantime the patient had improved, and the tumor grown more
firm.
Hence we are forced to conclude that the employment of con-
siderable wire within reason has some theoretical advantages,
without counterbalancing disadvantages, and that it has never
been given a fair trial, the question of " much wire or little wire"
still remaining an open one.
Strength of Current. Stewart and others insist upon the
use of rather a strong current — about 70 to 80 ma., as a rule.
Hunner objects to this, regarding it as dangerous from disinte-
gration of the sac wall, or even of the aorta itself in case of
misplacement of the wire. Hunner claims to have demonstrated
by his experiments that a current of lo ma. continued for fif-
teen or twenty minutes produces practically as large and effec-
tive a clot as one of lOO ma. used for a much longer period.
This seems hardly probable on the face of it, and, in addition,
in one of my operations, coagulation did not occur, as evidenced
by the movements of the needle for some thirty minutes after
the beginning of the operation. Hunner's experiments were
made in rapidly moving blood in a dog's aorta. Under such
conditions we know that clotting of blood is difficult to obtain,
as shown by several autopsies in which wire accidentally intro-
duced into the aorta remained perfectly clean. And it must
also be considered that where the circumference of the clots is
TREATMENT OF AORTIC ANEURISMS. 367
SO small relative differences are hard to estimate, which in larger
clots would be quite marked. Such an experiment is hardly a
fair test.
In my opinion more accurate data can be obtained by em-
ploying coagulated blood, because in aneurisms the blood does
not move with anywhere near the rapidity that it does within
the aorta ; and, in addition, it has been noted in many operations
that blood often clots shortly after turning on the electric cur-
rent ; hence we often operate, not only in comparatively stag-
nant blood, but even in a coagulum.
It will also be admitted, I am sure, that the solid clot, which
is, as it were, burned on to the wire, counts for much more in
the ultimate result than the soft coagulum which may form
around it. I found by conducting my experiments in clotted
blood that the diameter of the area acted on by a current of 100
ma. was several times greater than that effected by a current of
10 ma. during the same length of time — twenty minutes.
The danger of injuring the aorta or the sac-wall by a current
of 70 or 80 ma. is probably very remote (so far as known it has
never occurred), and is more than counterbalanced by the
advantages obtained.
(As a mere matter of interest, in blood prevented from coag-
ulating by the addition of sulphate of magnesia, I was able to
produce but a small amount of coagulum closely adherent to
the wire, and I could detect little if any difference between the
effects of currents of high power and those of low power.)
According to both Stewart and Hunner, the chief danger in
operating upon aneurisms with wire is the clotting of the blood
in but a portion of the sac, thus exposing the remainder to
increased pressure and possible rupture. This hypothesis,
however, does not seem reasonable. A sacculated aneurism,
according to the size of its opening, contains a more or less
comparatively quiescent pool of blood. When this pool is
struck by an impulse from the heart as it passes through the
aorta it expands, and this expansion, so say the laws of hydro-
statics, is equal in all directions. If a clot forms in a portion of
the cavity, this does not increase the pressure upon the re-
36S FREEMAN,
mainder of the wall. It does not even increase the general
blood-pressure, because nothing is added to the total quantity
of blood — in fact, the general blood-pressure, together with that
in the aneurism, is often lowered by the considerable loss of
blood which may take place during the operation.
In order to convince myself thoroughly on this point, I fas-
tened a rubber glove to a fountain syringe filled with water, and
elevated the syringe. The glove represented an aneurism, and
the force of the water in the douche-bag took the place of the
pressure of the blood, this force being measurable by the height
to which a fine stream of water was projected through a hole in
one of the glove-fingers. After the insertion of a large solid
body within the glove, to represent a clot, it was noticed that
the stream was projected to exactly the same height as before,
thus demonstrating that there was absolutely no increase of
pressure.
Conclusions, i. Considering the inefificiency of medical
treatment and the comparative efficiency of the use of silver
wire and electricity, it is probably better in favorable cases to
proceed to the latter at once, without wasting valuable time
upon the former. This seems all the more desirable when we
consider that wiring is not a very dangerous process, and that it
is in the early stages of an aneurism, when the sac is still firm
and the patient is in good condition, that the best prospect of
cure exists.
2. Soft, undrawn, unalloyed silver wire, devoid of spring, wire
just as it comes from the shop, is preferable to the hard, highly
drawn wire, alloyed with copper and full of spring. It is hardly
necessary to previously coil the wire.
3. It is still an open question as to which is preferable — a
large amount of wire or a small amount, with the theoretical
advantages in favor of the former.
4. A strong electric current is apparently preferable to a weak
one.
5. The canula through which the wire is introduced should
be inserted just within the sac and no further.
6. There is little if any danger of bursting the aneurism from
TREATMENT OF AORTIC ANEURISMS. 369
increase of pressure due to coagulation in a portion of the sac
only.
Cases. — I shall make these reports very brief. They will be found
more in detail in a paper by Dr. J. N. Hall;' likewise, many interest-
ing points relating to diagnosis, etc.
Case I. — Referred to me by Dr. George E. Tyler, of Denver, and
seen in consultation by Dr. J. N. Hall. Man, aged thirty-six years.
Syphilis. Aneurism of innominate and arch of aorta, size of child's
fist; had existed for seven months. Bulged into neck to right of
median line, and also anteriorly, dislocating clavicle and eroding
sternum. Violent expansile pulsation. Very soft, especially at one
point. Pain in arm and side of chest. Pressure on trachea — could
not breathe lying down. Pressure on recurrent laryngeal, with loss of
voice. Right pupil contracted.
The patient was weak and emaciated, and altogether in a desperate
condition. Dr. Tyler had tried rest, diet, and potassium iodide
without effect. Frequent injections of i per cent, and 2 per cent,
solutions of gelatin had proved utterly useless. Hence it was decided
to proceed at once to surgical measures. Under a local anaesthetic
(Schleich's solution) the common carotid and subclavian were tied
at one sitting, the patient standing the operation well. The effect of
this, although supplemented by gelatin injections, was but temporary,
the pulsations lessening in force for a day or two only. The tumor
then rapidly increased in size, dislocating the clavicle more markedly,
until bursting seemed imminent — a matter of a few days only. Wir-
ing was then decided on, and on September 28, 1900, eleven days
after the ligation, five or six feet of No. 27, undrawn, unalloyed silver
wire were introduced. A current of about 75 ma. was passed for thirty
minutes, the aneurism becoming firmer and pulsating less. The cur-
rent was turned on quite rapidly, the pulse becoming weak and the
patient's condition alarming for a short time ; but upon stopping the
electricity and proceeding with more caution the bad symptoms quickly
disappeared. It was thought at the time that the collapse was due to
a coil of wire penetrating the aorta, and a portion of wire was with-
drawn and again inserted, but this was probably not the cause.
Almost absolute rest was enjoined until January i, 1901. During
this time improvement was slow but continuous. In about five
' American Journal of the Medical Sciences, 1901, vol. ii.
Am Surg 84
370 FREEMAN,
months the tumor, which had long before ceased pulsating and
become solid, had almost disappeared ; the tracheal shock, as pointed
out by Dr. Hall, leaving long before the tracheal tug.
At the present time (April 25, 1901) no tumor is apparent, the
clavicle is no longer dislocated, there is no impediment to respira-
tion, no pain, and no auscultatory symptoms whatever, although the
voice, in spite of great improvement, is still husky. The man is at
work, without inconvenience of any kind, with a pick and shovel, on
the streets of Denver.
Curiously enough, the patient's collar has worn an opening through
the skin over the end of the wire, and a small sinus has been present
for the past two months, from which exudes a few drops of pus
daily.
Two attempts to show the wire by means of the Rontgen rays
utterly failed, an indefinite shadow of the contracted tumor being
the only result.
In the early part of July, 1901, the patient returned with a portion
of wire presenting at the mouth of the sinus. I easily removed the
wire, which lay in a small bunch within an abscess-cavity. In a few
hours a severe secondary hemorrhage (probably the result of ulcera-
tion) took place, followed by other alarming hemorrhages at intervals
of several days. The aneurism rapidly re-formed, causing compression
of the trachea, with coughing of some blood and very difficult respira-
tion. Although the man was in a desperate condition, another wiring
was done on July 13, 1901. About fifteen feet of soft, uncoiled wire
(No. 27) were inserted, and a current varying from 50 to 70 ma.
turned on for thirty-five minutes. The operation was well borne, but
the dyspnoea became progressively worse, death resulting in sixty-two
hours. Autopsy revealed a firm and satisfactory clot filling the entire
sacculated aneurism, with the wire coiled throughout its substance.
The fatal result was due not to hemorrhage, but to pressure on the
trachea, which had not been relieved by the operation.
Case II. — Man, aged fifty-six years. Referred to me by Drs. Shaw
and Collins, of Georgetown, Colorado, and Dr. Roberts, of Aguilar.
Had been an athlete, continuing active exercise up to the time at
which I saw him. Dr. J. N. Hall made a careful examination and
an accurate diagnosis of the size, situation, and general character-
istics of the tumor. The sac was attached to the ascending portion
of the aorta, just above the valves. It presented in the second inter-
costal space to the right of the sternum. There were practically no
TREATMENT OF AORTIC ANEURISMS. 3/1
auscultatory signs, expansile pulsation was marked, and the tumor
soft. Pain existed in the right side of the chest and ran down
the arm. It had been noticed for perhaps five months. No other
pressure symptoms. Dr. Hall, considering it a favorable case for opera-
tion, twenty-two feet of undrawn, unalloyed. No. 27 silver wire were
introduced under local anaesthesia on December 24, 1901. The
hemorrhage was t'ery free, almost alarming, the blood appearing when
the needle had been introduced but a short distance. A current of
75 ma. was employed for sixty-five minutes. Again, the current was
turned on too rapidly, producing a weak and slow pulse, and symptoms
of collapse lasting a few minutes.
Although improvement took place in pain, expansile pulsation, and
consistency, the tumor continued to extend toward the axilla. An-
other wiring was done on February 20, 1901, some eight or nine feet
of wire being used, the sitting lasting seventy-seven minutes. The
strength of current varied between 50 ma. and 80 ma.
Again, improvement was noted, but althoughi harder and without
appreciable expansile pulsation, the up-and-down movement was so
marked that another operation was decided on. This was done on
March 13, 1901, but, although the canula was inserted to the hilt,
about two inches, nothing but a little serum was obtained. Two or
three feet of wire were pushed in with difficulty, and 75 ma. turned on
for about seventy minutes.
More solidification and contraction followed, although the heaving
pulsation was still quite evident, as it must be as long as a tumor rest-
ing on the aorta is present.
On April 29, 1901, an exploratory puncture was made, and blood
reached at a depth of one and a half inch, although it did not
spurt through the needle as on former occasions, but merely welled
out in moderate amount. Another wiring was done on April 30,
1901, five or six feet of drawn and coiled silver wire being inserted,
and a current of 75 ma. turned on for seventy-two minutes. Pulsation
almost entirely ceased at the end of about half an hour, and the
needle, which had previously moved freely with each beat of the heart,
rested almost without motion, showing that a satisfactory clot had
been obtained.
This case, although not cured at once, has shown continuous
improvement. The vi^all, which was at first thin, has thickened
to one and one-half inch; the expansile pulsation has almost
372 FREEMAN,
if not quite ceased, and the consistency has increased to a
marked extent. In addition, the blood, which at first spurted
several feet through the canula, at the last puncture did not
spurt at all, showing that it existed as a stagnant pool in the
centre of a firm, thick clot. What the outcome will finally be
it is impossible to say, but the outlook seems encouraging. A
letter received from this patient on August 5, 1901, stated that
his condition was satisfactory in every respect.
To Dr. E. P. Hershey, of Denver, the first to successfully
wire an aneurism in Colorado, I desire to express my indebted-
ness for valuable assistance.
TREATMENT OF AORTIC ANEURISMS. 373
DISCUSSION.
Dr. J. M. T. Finney, of Baltimore.
My own personal experience in the wiring of aneurisms is based
upon 8 cases in which I have wired an aneurism of some portion of
the aorta. Four of these cases were thoracic and 4 abdominal aneu-
risms. I have observed 2 other cases — i abdominal sac, operated
upon by Dr. Halsted, and i thoracic aneurism, operated upon by Dr.
Stewart, of Philadelphia.
Of my own cases, 2 were apparently cured ; in 2 the symptoms
were temporarily relieved to a greater or less extent; in 2 death was
undoubtedly hastened by the wiring ; in 2 others the operation has
been too recent to form any idea of the ultimate result, although the
immediate effect has been satisfactory in relieving pain and reducing
the size and impulse of the sac.
In my experience the good effects of the wiring have not necessarily
been immediate, but in the 2 cases where the operation effected a
cure the results were not at once apparent. One of these cases, a
sea captain with a large thoracic aneurism, probably of the ascending
portion, was under observation for a num.ber of months; finally the
swelling and symptoms having practically disappeared, and having
been pronounced probably well by Dr. Osier, he went to sea. After
some weeks he was taken ill, and died a few hours later. It was im-
possible to get any satisfactory history of his illness, so the cause of
death must remain unknown.
The other case was recently examined by Dr. Osier over a year after
the wiring, and was pronounced by him as probably cured, the orig-
inal aneurismal sac having decreased very much in size, and the im-
pulse being very slight.
Of the two cases that were temporarily benefited, one a patient of
Dr. Johnston, of Washington, was of enormous size ; the benefit here
was noted in the diminution of pulsation and relief of pain. The
aneurism finally expanded in another direction and later ruptured.
The other case was wired three times ; wiring was done at different
places. He was relieved considerably after each operation, but finally
died of exhaustion.
Of the two fatal cases, in one the sac was burned so badly by the
strength of the electric current at that point that it afterward rup-
374 DISCUSSION.
tured. The other case, an abdominal aneurism high up, had been
apparently considerably relieved by the wiring, when suddenly, about
a week following the operation, the patient died with symptoms sug-
gesting pulmonary embolism or possibly rupture of the sac. We were
unable to obtain an autopsy.
Of the other two cases, one abdominal and the other thoracic, it is
too early to speak, although they both report themselves as feeling
better than before the operation, and there has apparently been some
decrease in size and amount of pulsation.
As to the technique of the operation, we have followed that described
by Dr. Hunner in a recent paper, published in the Johns Hopkins
Bulletin. We should advise the use of cocaine where practicable ;
we were able to use it in two of our abdominal cases. Of course, a
general anaesthetic is not necessary in thoracic cases. The method of
preparation and sterilization of the wire, needle, etc., was then shown,
and a demonstration given of the technique of the operation.
Dr. De Forest Willard, of Philadelphia.
I have I case (which is still under treatment) of an enormous trau-
matic thoracic aneurism which fills the entire right thorax. Four
months ago I introduced silver wire and applied electricity. The
relief from the pain has been so great that, even if these cases do not
recover, it seems to me that it is advisable to institute this form of
treatment. It was very gratifying to find such improvement in the
man, and he was made perfectly comfortable. He is a man whom
one cannot control, and in spite of his aneurism will use unnecessary
muscular exertion. The improvement has been exceedingly great,
but there is now an extension of the sac toward the right axilla. I
hope to induce him to submit to a second operation, which will un-
doubtedly prolong his life for several months, although I hardly believe
it possible to secure a perfect cure.
A moderate quantity of wire is desirable, and I am in favor of fill-
ing the sac quite thoroughly, so as to make many points of clot. A
moderate current is also advisable, since an excessive current may do
harm, and we simply want sufficient to cause a coagulation around
the coils of wire — i.e., about lo to 20 milliamperes.
Dr. R. Matas, of New Orleans.
Dr. Freeman's results are admirable, and I congratulate him. I
regret that my experience has not been so fortunate. I have recently
TREATMENT OF AORTIC ANEURISMS. 375
reported two cases, one of which was operated by my colleague, Dr,
Parham, in 1896, in which death followed after a survival of forty-five
days, from the migration of the wire into the aorta and the heart, and
my patient's case in which death followed nineteen days after wiring
and electrolysis, from secondary rupture of the sac, caused by defective
conditions inherent to the method itself. These cases, with a critical
analysis of others reported in the literature, will appear in the Trans-
actions of the Southern Surgical and Gynecological Association for
1900. While my study of the method in its relations to abdominal
aneurism has led me to look upon it unfavorably, as a whole, I recognize
that the conditions in the thorax are different, and that it is of some
value is well shown by Dr. Freeman's interesting cases.
In view of the great attention given to the technique of the Moore-
Corradi procedure, its applications deserve more than passing notice.
The indications and limitations of this method have not been studied
sufficiently. In our anxiety to perfect the technique we have over-
looked the anatomical conditions which contraindicated its applica-
tion. Undoubtedly great improvements have been made in the
technique, but these are of little help to the patient when we consider
that the cure of the aneurism by this or any other coagulating
method may lead, ipso facto, to the death of the patient by obliterating
the orifice of important visceral branches; and what is worse, that this
unfortunate result is most likely to follow after wiring the aneurisms of
the upper or cceliac division of the abdominal aorta, /. e., in about 50
per cent, of the cases ! Other grave objections could be presented,
but this one alone is sufficient to make us pause before resorting to so
dangerous a procedure.
Dr. Freeman. Whether the formation of a clot in a portion of an
aneurism will result in increase of tension in the remainder, and rup-
ture, is open to doubt. The general arterial tension is certainly not
increased ; it is rather decreased, owing to hemorrhage, which nearly
always takes place during the operation. An aneurism represents a
more or less separate pool of blood lying beside the aorta, and when
a wave from the heart strikes this pool expansion takes place which is
equal in all directions. The force of this expansion would not be
increased by the formation of a clot in a portion of the sac. This can
be illustrated, as I have stated in my paper, by means of a rubber
glove filled with water under a given pressure, into which is intro-
duced some substance to represent a clot. It will be found that the
376 TREATMENT OF AORTIC ANEURISMS.
pressure, measured by a stream of water forced through a hole in the
glove, is not increased. The ruptures which have followed wiring
have not been due, in my opinion, to increased pressure, but to the
fact that the aneurism has been just on the point of rupture, and the
operations have failed to check this unfortunate outcome.
The remarks of Dr. Matas refer, of course, to the abdominal aorta
alone, and here they possess some foundation, although cures have
resulted. As regards the thoracic aorta, however, the case is entirely dif-
ferent. Here the operation does not seem to be very dangerous, and
the results have been better than those obtained by any other method.
DOUBLE RENAL CALCULUS.
By S. J. MIXTER, M.D.,
BOSTON, MASS.
L. N., machinist, aged twenty-seven years, entered the Massachu-
setts General Hospital on August 23, 1900. When between seventeen
and twenty-five years old he had several attacks of renal colic on each
side, followed by the passage of small stones twice the size of head of
pin. During these years often passed gravel "size of iron filings."
Now, when walking or working, has a dull aching pain just under
ribs on right side, the pain sometimes extending around to back.
Urine is at times " as red as blood," and sometimes contains gravel.
He is a well-developed and nourished man, and has worked at his trade
up to time of entrance to the hospital. Kidneys cannot be felt, and
there is little if any tenderness in renal regions.
Urine. Slightly acid, 1012 ; slight trace of albumin. Rare hya-
line cast ; frequent small and large round cells ; rare squamous cells ;
many leucocytes; a few fresh blood corpuscles; very many triple
phosphate crystals.
An X-ray showed large shadows in region of each kidney, so large
that it was thought to be accidental, but four other plates showing the
same thing, there remained no doubt as to the presence of stones in
both kidneys.
On September 5th the left kidney was operated on, the usual in-
cision showing a healthy looking and but slightly enlarged kidney, in
which could easily be felt a large irregular stone. The kidney was
split on its posterior border nearly its whole length, and the stone was
removed in two parts. There were originally two stones, as shown by
the faceting, but they were cemented together by a thin layer that
covered them both. The whole mass weighed 1020 grains.
During the operation hemorrhage was quite profuse from the kidney,
and was easily controlled by gauze packing.
378 MIXTER,
Recovery was uneventful. All packing was removed by the sixth
day, and urine entirely ceased flowing from the wound in eighteen
days.
On February ii, 1901, he again entered the hospital for operation
on the other kidney. An X-ray showed no sign of stone on left side,
but a fairly large one on right. The operation was on February 14th.
The kidney was found to be almost normal in appearance, the pelvis
being somewhat dilated. Two perfectly smooth round stones were
removed, weighing 220 and 20 grains.
Urine escaped from the wound for about two weeks, and the patient
left the hospital two weeks later.
This case is especially interesting as showing how large a mass of
stone maybe present in the kidney without seriously affecting its struc-
ture or functions. Suppurating kidneys, containing large masses of
stone are not uncommon, but the whole organ is generally converted
into a sacculated bag, full of pus, and the renal tissue is seriously
degenerated. Such cases almost always demand removal of the organ,
or a permanent suppurating fistula follows incision.
Skiagraphs were most useful in this case as showing the relative size
of the stones and their presence in both kidneys.
DOUBLE RENAL CALCULUS. 3/9
DISCUSSION.
Dr. J. M. T. Finney, of Baltimore.
I have recently operated upon a very interesting case of stone in
both kidneys. A positive diagnosis of stone was made in the right
kidney, and it was thought probable that a small one existed also in
the left, although this could not be definitely determined.
I had seen the patient two years previously ; he then gave symp-
toms suggesting stone in the right kidney. I advised an exploratory
incision, but it was declined. He again entered the Johns Hopkins
Hospital a few weeks ago, saying that after a severe attack of grippe
his trouble referred to in the right kidney had much increased. Exam-
ination of the urine showed nothing definite but a large amount of
pus.
Dr. Young kindly catheterized the ureters and secured a clear speci-
men from the left kidney, while that from the' right contained a large
amount of pus.
Dr. Brown kindly took a number of skiagraphs and demonstrated
the presence of a large stone in the right kidney, for some reason or
other the skiagraph of the left kidney was negative. Upon the
strength of these examinations I advised and performed a nephrot-
omy of the right kidney, and removed a large branching stone. The
kidney itself was much disorganized. There was complete suppres-
sion following the operation, and the patient died on the fourth day
of uraemia.
The autopsy revealed a very interesting condition ; the left kidney
showed a double pelvis and ureter for about six inches down. A
large branching stone filled the lower pelvis. A small portion of this
stone had broken off and plugged completely the orifice of that branch
of the ureter just above the bifurcation. This lower half of the kid-
ney was little more than an abscess cavity. The upper half of the
kidney was comparatively normal. The explanation then of the
results of Dr. Young's catheterization was that the catheter had col-
lected the urine only from the upper portion of the left kidney, which
was practically the only good kidney substance that the patient had,
the lower portion of that kidney and the whole of the right kidney
being very much disorganized.
This case simply illustrates how even the most thoroughly scientific
methods of diagnosis may be at times misleading.
A NEW METHOD OF CLOSING THE WOUND IN
THOROUGH REMOVAL OF THE BREAST.
By S. J. MIXTER, M.D.,
BOSTON, MASS.
Operations for the removal of malignant tumors of the breast
should be done for two purposes : first, to endeavor to secure a
radical cure in cases not too far advanced ; and, second, to
remove a sloughing or painful mass where a cure cannot be
expected. It is in the first class of cases that the surgeon
should do the most thorough operation possible, and as a gen-
eral rule the smaller the malignant mass the greater should be
the sacrifice of the surrounding tissues.
Thorough local removal I believe to be fully as important as
a thorough dissection of the axilla and often the subclavian
region, the skin, breast and pectoral muscles being removed in
one mass, the clavicular fibres of the pectoralis major being left,
unless the disease is in the upper part of the breast.
The skin incision should begin well above the anterior fold
of the axilla, so that after the removal of the pectoralis the scar
will still be in front of and not across the axilla. From here
sweeping around the breast to the middle line, everything is
removed to the ribs and intercostals.
Such an incision leaves a large defect to be closed, and even
in patients whose skin slides fairly well, there would be an un-
covered space larger than the hand should an attempt be made
to suture without some form of plastic operation. Skin-graft-
ing, either at the time of the operation or later, will cover
the ribs, it is true, but the resulting scar is thin and very
uncomfortable.
THOROUGH REMOVAL OF THE BREAST. 38I
In more than 20 suitable cases I have lately closed this defect
by sliding or transplanting the opposite breast, so that the nip-
ple comes at the median line.
An incision is made from the lower and inner median angle
of the original incision, carried directly across beneath the
sound breast, and then curved upward to the posterior fold of
the axilla. The breast and surrounding skin are then dissected
from the underlying fascia, care being taken not to divide the
branches that run to it directly from the axilla or those that
are about the outer part of the clavicle. The skin should be
thoroughly separated from the deep tissues over the attachment
of the sternomastoid.
If now the knife be carried under the skin and subcutaneous
tissues below the lower border of the incision, exposing the upper
part of the abdominal fascia, it will be found that the defect can
be easily closed without undue tension. In some cases a short
vertical incision just below the middle of the sound breast and
extending to its border gives additional length to the flap.
In no case have I had the slightest trouble with the flap.
There has always been primary union, and no sloughing has
followed the extensive dissection. The nipple that at the time
of the operation is in the median line draws over somewhat
toward its natural situation owing to the flattening of the breast.
I may add that no patient has complained of the slight de-
formity resulting.
382 THOROUGH REMOVAL OF THE BREAST,
DISCUSSION.
Dr. J. Collins Warren, of Boston.
The question of what to do after removal of the breast is an im-
portant one, as very often patients are sensitive to the deformity. The
aesthetic side of the operation must be taken into the account, and it
is with this idea in view that I have tried to devise a plan of closing the
wound. If we could get a linear scar it would be the best thing to do.
The operation as performed by Dr. Mixter seems to work smoothly ;
there is no tension, and the wound heals quickly, but it alters the
woman's shape and makes her appear pigeon-breasted. The outlines
of the body are something that a woman prizes highly in making her
toilet. By taking a flap from the side the wound can be closed with-
out additional deformity.
Dr. W. H. Carmalt, of New Haven, Conn.
I had a case of recurrent carcinoma of the breast to operate upon,
in which the defect left after the removal of the growth was too large
to be filled up by any ordinary sliding operation from the immediate
neighborhood ; and, as I object most decidedly to let this class of cases
heal by granulation, I employed a procedure similar to that described
by Dr. Mixter of transplanting the other breast to assist in covering
in the defect with a good result. I cannot from memory (this was
several years ago) describe the incisions — one "cuts his coat accord-
ing to the cloth" in plastic surgery — but the wound healed by first
intention, and the woman expressed herself afterward as entirely satis-
fied with the result.
RESECTION OF A LARGE PART OF THE CHEST
WALL FOR A SARCOMA; USE OF FELL'S
APPARATUS FOR ARTIFICIAL RESPIRA-
TION; LATE CONTINUOUS FEVER DUE
TO STAPHYLOCOCCUS BLOOD IN-
FECTION; SUCCESSFUL USE OF
THE ANTISTREPTOCOCCIC
SERUM; COMPLETE
RECOVERY.
By W. W. keen, M.D., LL.D., F.R.C.S. (Hon.),
PHILADELPHIA.
L. H. (colored), a woman, aged twenty-five years, was admitted to
the Jefferson Medical College Hospital, October 7, 1900. Her father,
mother, and five brothers and sisters are living and well ; one brother
has a growth the size of a walnut under the angle of the jaw ; two
brothers died of dysentery ; one aunt with a tumor, at the age of
forty, and another is very ill with an abdominal tumor. There is no
tubercular family history. She had the ordinary diseases of childhood
when quite young. She first began to menstruate at sixteen. There
is no history of specific infection.
On December 24, 1898, she was thrown out of a wagon, and injured
her right side, but not so severely as to prevent her continuing her
housework. In March, 1900, she first noticed a small growth about
the size of an egg at the lower angle of the right scapula. This growth
has gradually increased in size, and has been the seat of a dull, aching,
almost constant pain, excepting at irregular short intervals, when it
becomes very intense and radiates as far as the median line anteriorly.
At present deep respiration causes pain.
On admission there was found to be a tumor in the right postero-
lateral aspect of the chest, extending from the edge of the erector
spinse mass to the outer border of the right breast, and from the fifth
384
KEEN,
to the eleventh ribs inclusive. It measured 15 cm. vertically, 26 cm.
horizontally, and was elevated about 7.5 cm. above the general level
of the chest. There was no infection of the overlying skin, nor was
this adherent. The tumor itself was fixed, only slightly lobulated,
and was not tender. Her appetite was good, bowels regular, tongue
slightly coated, heart and lungs normal.
The blood-count on October i6th was as follows: Erythrocytes,
4,100,000; leucocytes, 7000; haemoglobin, 60 per cent.; polymor-
phonuclear neutrophiles, 65 per cent.; small lymphocytes, 22,5 per
cent. ; large lymphocytes, 10 per cent. ; eosinophiles, 25 per cent.
Fig. I.
Tumor before operation.
Urine : Specific gravity, 1026 ; acid ; no albumin or sugar ; urea,
1.9 per cent. By the microscope, amorphous urates, a few squamous
epithelial cells ; no crystals, pus, blood, or tube casts.
My diagnosis was a sarcoma involving the chest wall, but presum-
ably only beginning to invade the cavity of the chest without any
evidences of adhesions of the lung. The same conclusion was reached
by Prof. James C. Wilson, who kindly examined her chest for me with
great care. In view of the facts set forth in Dr. F. W. Parham's
" Thoracic Resection for Tumors Growing from the Bony Wall of the
RESECTION OF THE CHEST WALL FOR A SARCOMA. 385
Chest," I decided to use Fell's apparatus for artificial respiration at
the time of the operation.
Operation, October 17, 1900, in the Jefferson Medical Hospital
clinic. I made a large horseshoe-shaped, flap by an incision begin-
ning at the outer border of the right breast, extending downward to
the eleventh nb, and sweeping backward and upward quite near the
vertebral spinous processes as far as the level of the inferior angle of
the scapula. This flap, consisting only of skin and the muscles over-
lying the tumor, was then reflected upward. In doing this I was
extremely careful not to include any of the tumor in the flap. I then
Fig. 2.
Tumor before operation.
was able to introduce my hand under tlie lower border of the tumor,
and found that, like a mushroom, it had a base considerably smaller
than the body of the tumor. Accordingly, in order to remove as
little of the chest wall as was possible, I gradually tore the tumor
loose from the ribs and peeled it off" entirely. A second advantage,
beside the smaller amount of chest wall resected, was that I was able
to divide the diseased ribs anteriorly and posteriorly at selected points
at a sufificient distance away from the disease before opening the
pleural cavity, which last would probably involve the collapse of the
lung. A third advantage was, that, having divided the bones, I would
be able to divide the soft parts very rapidly, and so diminish the
Am Surg 25
386 KEEN,
period during which collapse of the lung, especially the initial col-
lapse, would be a threatening danger.
I found that the fifth, sixth, seventh, and eighth ribs, and the tissues
between them, were all diseased, but the ninth, tenth, and eleventh
were free. I first separated the pleura from the anterior surface of the
ribs by a periosteal separator, and by means of bone forceps divided
each of these four ribs anteriorly and posteriorly without invading the
pleural cavity. Then, with a pair of scissors, I rapidly divided the
soft parts, including the pleura, and in a moment had removed the
entire tumor, and made an aperture in the chest wall measuring verti-
cally 18 cm. and horizontally 12 cm. I found that the tumor was
just bulging the pleura inward, but had not yet contracted any adhe-
FlG. 3.
Tumor removed, one-fourlh natural size.
sions with the lung, but soon would have done so. As soon as I
opened the pleural cavity the lung collapsed. Fell's apparatus for
artificial respiration was immediately put in use by Dr. Spencer. It
was used by means of a face mask which covered the mouth and
nose, but was not air-tight. For this reason it did not work
satisfactorily, and the collapsed lung was only very slightly filled
with- air. But, fortunately, the patient suffered very little indeed
from the practically almost total and immediate exclusion of the right
lung from any part in respiration. While I was doing the earlier part
of the operation, one of my assistants had laid bare a vein at the bend
of the elbow in the opposite arm, but without opening the vein, so
that he was ready at an instant's notice to proceed to transfusion had
RESECTION OF THE CHEST WALL FOR A SARCOMA. 387
it been necessary. As at no time during the operation did the neces-
sity arise, the wound was closed at the end of the operation, and gave
no further trouble.
As soon as I had made the large opening in the chest wall, I seized
the lung with my hand, drew it up to the opening, and as rapidly as
possible, with a long, continuous catgut suture, sutured the lung to the
edge of the opening throughout its entire circumference. In doing
so I passed a curved Hagedorn needle directly through the lung tissue,
puncturing it perhaps to the depth of 2 to 3 cm. As the traction
on the upper and lower portions separated the two lobes, I sutured
these two lobes together at two points, the object of one of these sutur-
ings being to diminish the resulting space for a pneumothorax. The
flap was then placed in position, sutured at close intervals, and the
wound sealed with iodoform collodion throughout. At the end of
the operation the patient was in a very good condition.
The following observations were made by Dr. J. W. Macintosh, who
had charge of the anaesthetic.
1.30 p M. Operation begun.
2.10. Pleural cavity opened ; respiration, 26; pulse, 118.
2.15. Respiration, 24; pulse, 120.
2.20. Respiration, 30; pulse, no.
2.25. Anaesthetic stopped.
In spite of the character and length of the operation, the tempera-
ture fell only to 97.2° after the operation. On the second day it rose
to 100.6, and from the fourth day (October 21st) to the sixteenth
day (November 7th) fluctuated between 100° and 102°. Neither
myself nor my house surgeon. Dr. Swartz, nor Professors J. C. Wilson,
W. Joseph Hearn, or J. Chalmers Da Costa, all of whom, at my re-
quest, examined the patient, could find any post-operative evidence
either of a pneumothorax or a pyothorax. Very little traumatic
pleurisy and no recognizable effusion followed the operation, though
the patient suffered moderately from pain at the site of the operation.
This was very gratifying, especially in view of the suturing of the
lung to the edge of the opening.
Not being able to find any local reason for the continued high
temperature, I asked Dr. F. J. Kalteyer to examine the blood. This
was done on November 7th, the blood being drawn by Sittmann's
method. The result was as follows :
"Erythrocytes, 3,425,000 per cubic millimetre; leucocytes, 18,000
per cubic millimetre ; haemoglobin, 34 per cent. ; color index, 0.5,
388
KEEN,
"Differential count of the leucocytes: Polymorphonuclear neu-
trophiles, 95 per cent. ; small leucocytes, 2 per cent. ; large lympho-
cytes, 3 per cent. ; eosinophiles, o.
" Plates were made and tubes inoculated. One plate at the end of
forty- eight hours showed five colonies. Three of these were whitish
in color and slightly granular in appearance and circular in outline.
Spreads were made and stained with Loefifler's methylene-blue and by
Gram's method. The growths were found to be staphylococcus pyo-
genes albus in pure culture. The remaining two colonies consisted
of pure cultures of the baccillus subtilis, a probable contaminating
organism. The other plate remained sterile after seven days."
Fk;
Appearance after operation.
The use of the antistreptococcic serum (Parke, Davis & Co.), in
doses of ID c.cm., was begun and continued once daily from Novem-
ber 9th to 14th inclusive, six injections in all being given. The tem-
perature immediately began to fail, and dropped progressively till it
reached the normal on the 14th, when the injections were discon-
tinued. After that there was no rise above 99°. On the 15th, and
again on the 27th, the blood was re-examined, and was proved to be
sterile in each instance. Shortly after this she went home well. Fig. 4
shows the final result.
Professor Coplin made the following pathological report on the
specimen :
I
RESECTION OF THE CHEST WALL FOR A SARCOMA. 389
"The specimen consists of a semi-ovoidal mass of tissue, 18 cm.
long, 12 cm. wide, and 6 cm. thick; weight, 625 grammes.
"On the convex surface is a triangular area of muscular tissue, 2
cm. thick on one edge, tapering to a tendinous insertion on the
opposite side. The course of the fibres correspond in general to the
long axis of the tumor. The muscular mass is rather firmly attached
to the tumor beneath. A second piece of muscle, i cm. thick, 2 cm.
wide, and 10 cm. long, runs from one edge diagonally across the
tumor and terminates near the insertion of the previously described
muscle. A delicate layer of connective tissue attaches the muscle to
the tumor and extends over the uncovered parts of the tumor.
"The inferior surface is oval in outline, and presents muscle fibre
generally scattered over the surface. Three, distinct elevations, 0.5
cm. high and 0.5 cm. long, are demonstrable upon this surface.
Finally, sections of four ribs, three 11.5 cm. long, one 6 cm. long,
are attached. Interstitial muscular structure holds these fragments
firmly together. On the inner aspect of the tib sections, and par-
tially covering the middle two, is a pale yellow elevation of tissue,
4 cm. long, 2 cm. wide, i cm. thick. This tissue is rather firm,
slightly nodular, and has attached to its upper margin, extending
from the middle of the mass to 3 cm. beyond it, a ribbon of appar-
ently the same tissue as the nodule. A similar ribbon extends along
the lower edge 3 cm. beyond the nodule to either side. This nodule
is a projection of the tumor between the ribs (toward the pleura),
and, in common with the remainder of the concave aspect of the
surface, is covered by what appears to be a serous membrane. In
order to avoid mutilation of the specimen the ribs were not sectioned,
but no gross evidence of infiltration by the tumor is to be recognized.
"Specimens were fixed in Heidenhain's solution and stained with
haematoxylin and picric acid, toluidin-blue, and by other combina-
tions.
"The tissue is composed largely of spindle-cell elements, which
cells are arranged in a highly interwoven texture. These cells have
interspersed among them elements of multipolar outline tending
strongly in appearance to myxomatous cells. The bodies described
are in a matrix of fibrous formation resembling that observed in
fibromata.
" Mast cells are to be observed with varying frequency, but on the
whole are not very numerous.
" Sections from the intercostal and subparietal pleural growth show a
390 KEEN,
much closer aggregation of the types of cells described, in addition to a
large number of round cells possessing the same morphology and tinc-
torial reactions of lymphoid cells situated immediately beneath the
pleura. The lymphoid cells are particularly numerous at either end
where the growth terminates in the ridges described in the gross
specimen. These ridges are of adipose tissue somewhat infiltrated by
lymphoid cells. The pleura has lost its characteristic histological
structure, becoming somewhat fibrous. Mast cells are present, but
less numerous than in the other sections of the tumor.
"The bloodvessels are numerous and highly atypic, being simply
channels lined by the spindle cells before described. Around a few
of the bloodvessels a lymphoid cell infiltration is observed.
" Diagnosis. — Spindle-cell sarcoma. The cellular elements are for
the most part of the so-called small-fpindle type, but large spindle
cells and numbers of multipolar cells are also present. No satisfac-
tory explanation for the presence of elements morphologically identi-
cal with lymphoid cells can be given. Their possibly inflammatory
origin cannot be excluded."
Remarks. There are a few points to which I would call
special attention :
1. The method of separating the tumor from the chest wall
so as to determine more exactly the limits of the disease and
lessen the size of the opening to be made in the chest.
2. The division of the ribs anteriorly and posteriorly prior to
opening the pleural cavity. This diminishes by so much the
period of danger in collapse of the lung.
3. The use of Fell's apparatus, which was not satisfactory in
this case, and for which I would prefer to substitute the apparatus
of Dr. Bloom, of New Orleans, which I have the pleasure of
showing the Fellows, or the apparatus of Dr. Matas, which he
now is to demonstrate to the Fellows. Probably the defective
use of Fell's apparatus was due to the mask.
4. The suture of the lung to the chest wall. This was fol-
lowed by no untoward surgical result. It diminished very
greatly the amount of post-operative pneumothorax, and, in
fact, one might almost say averted it.
5. Whether the use of the antistreptococcic serum was the
RESECTION OF THE CHEST WALL FOR A SARCOMA. 39I
cause of the fall of temperature or only a coincidence one can
hardly say, but the results seemed to be quite striking.
6. The examination of the blood was of great value, as
showing the reason for the continued high temperature, and led
to what I believe to have been the proper treatment for this
condition.
7. It is, of course, too early to determine what her future will
be, but up to the present time, a period of nearly seven months,
the results have been eminently satisfactory, no recurrence being
yet observed.
ARTIFICIAL RESPIRATION BY DIRECT INTRA-
LARYNGEAL INTUBATION WITH A MODIFIED
O'DWYER TUBE AND A NEW GRADUATED
AIR-PUMP IN ITS APPLICATIONS
TO MEDICAL AND SURGI-
CAL PRACTICE.
By RUDOLPH MATAS, M.D.,
NEW ORLEANS.
In two communications, one contributed to the Transactions
of the Louisiana State Medical Society, in May, 1898/ in which
I suggested the advantages of the Fell-O'Dwyer apparatus as a
means of preventing and overcoming the effects of acute trau-
matic pneumothorax in thoracic operations, and the other,
pubhshed in the Transactions of the Southern Surgical and
Gynecological Association, in November, 1899," I have dis-
cussed the historical, physiological, surgical, and, to some extent,
the mechanico-therapeutical phases of acute traumatic pneumo-
thorax. In these communications I have endeavored to demon-
strate that intralaryngeal insufflation is a most valuable auxiliary
in meeting the emergencies of surgical practice whenever the
respiratory function is compromised and imperilled by acute
surgical atelectasis.
While especially considering the advantages of insufflation or
artificial respiration with mechanical aids in its applications to
thoracic surgery, and more particular in those conditions met in
1 The Surgery of the Chest, etc. Transactions of the Louisiana State Medical Society,
May 10-12, 1898 ; also Annals of Surgery, vol. xxix., 1899, pp. 409-434.
2 Intralaryngeal Insufflation for the Relief of Acute Surgical Pneumothorax, etc.,
Transactions of the Southern Surgical and Gynecological Association, November, 1899 ;
also Journal of the American Medical Association, June 9, 1900.
ARTIFICIAL RESPIRATION WITH AN o'dVVYER TUBE, 393
intrapleural and mediastinal work in which collapse of the lungs
occurs in consequence of the sudden entrance of air into the
pleura through large openings or fenestra in the chest wall, I
have also considered the advantages of mechanical appliances in
maintaining artificial respiration in conditions of asphyxia due
to other non-surgical causes. Among these the most desirable
is a reliable means of maintaining prolonged artificial respira-
tion in chloroform and ether asphyxia; in acute cocaine poi-
soning and opium narcosis ; in respiratory failure from bulbar
paresis — e. g.^ in drowning, in poisoning from illuminating gas
and other deoxidizing gases ; in the paresis caused by the
increased intracranial tension due to cerebral hemorrhage, con-
tusion, etc.
Without detaining you with the consideration of the histori-
cal and evolutionary phases of the question, which I have fully
presented in the contributions referred to, I will simply recall
the fact that artificial respiration for the relief of asphyxia due
to suffocation and drowning had already attained a remarkable
degree of development as early as 1829, when various pumps
and bellows for simple insufflation and for combined insufflation
and aspiration of the lung had been devised by several inge-
nious experimenters (Monroe's, Goodwin's, Hunter's, Nooth's,
John Murray's, Cap's, among others). But a decided setback
was given to the practice of artificial respiration with mechani-
cal aids by the exhaustive experimental research undertaken by
Le Roy d'Etiolles in 1829, who, in a memoir addressed to the
French Academy of Sciences, adversely criticised the methods
of insufflation then in vogue, and showed their objectionable
and dangerous features when indiscriminately and unskil-
fully applied. He based his conclusions on numerous experi-
ments made on rabbits, foxes, goats and sheep, in which death
had been observed to follow with alarming frequency as a result
of the sudden and forcible insufflation of air into the trachea.
The French Academy appointed a special committee, consist-
ing of DumeriJ, and the celebrated physiologist, Magendie, who
confirmed Le Roy's observations, and extended his experiments
to the dead bodies of newborn infants and adult human cadav-
394 MAT AS,
ers. These observations showed that the sudden violent injec-
tion of air into the lungs often caused acute emphysema, rupture
of a smaller bronchi, and laceration of the lungs, with the pro-
duction of acute pneumothorax and secondary collapse of the
lungs. After this discouraging report nothing was done to
advance the practice of artificial respiration by mechanical aids
until 1845, when a new movement was vigorously started in its
favor through the exertions of Chaussier and Depaul, the emi-
nent professors of obstetrics at the Faculte. Depaul, who was
particularly vigorous in his agitation of the subject, and his fol-
lowers only developed one phase of the question, but this was
in a very important direction, viz., the application of insufflation
in asphyxia neonatorum by means of a tube introduced directly
into the larynx through the glottis. Intraglottic tubes of various
designs were devised to be used as blow-pipes by the opera-
tor, or were connected with rubber bulbs which forced the air
into the larynx through the canula. Artificial respiration by
intralaryngeal intubation and insufflation was relegated almost
exclusively to the accoucheur, and nothing was done to advance
or perfect its application to the emergencies of surgery until the
last decade, when the rapid and ever-increasing assaults made
by surgery upon the lesions of the intrathoracic organs aroused
a new interest in the literature of intrathoracic operations and
created a demand for a reliable means of counteracting the
dangers of asphyxia and pneumothorax. Quenu and Longuet^
Tuffier and Hallion, Doyen and H. Milton, of Cairo, and pos-
sibly Pean, had all realized the possibilities of mechanical
insufflation, and had made notable experimental and clinical
contributions to the technique in 1897-1898, but with the excep-
tion of Doyen's apparatus, which he had described in 1898, a
simple and reliable appliance for the practice of artificial respir-
ation had not been devised or put to the test of clinical experi-
ence in Europe.
Doyen, it is true, had invented and fully described his com-
pound bellows, which, when attached to an intralaryngeal
canula, was capable of maintaining rhythmical artificial respira-
tion by insufflation and aspiration. This apparatus is figured
I
ARTIFICIAL RESPIRATION WITH AN O DVVYER TUBE. 395
in his Technique Chmirgicale , published in 1897, but there is no
reference in his book or his subsequent publications to any
experimental or clinical application of his invention. About
this time (1897) I received a copy of the medical and surgical
reports of the Presbyterian Hospital of New York for 1896,
which contained a brief but excellent article by Dr. Northrup, in
which he demonstrated the value of the Fell-O'Dwyer appa-
ratus as an aid to artificial respiration in the treatment of opium
narcosis and other non-surgical conditions. Too much credit
cannot be given Dr. Northrup for his persistent advocacy of this
valuable apparatus, the invention of his lamented and ingenious
colleague, O'Dwyer. The reading of this article, together with
the repeated demonstration of its unfailing and almost marvel-
lous efficiency in cases of opium narcosis at the hands of Dr.
J. D. Bloom, surgeon in charge of the Charity Hospital of New
Orleans, immediately suggested to my mind that this was the
apparatus needed in thoracic surgery.
The suggestion grew upon me, and it was my confidence in
its value that led me to take it as a basis of an address before
the Surgical Section of the Louisiana State Medical Society in
May, 1898. Since then the clinical confirmation of the value
of the principle of intralaryngeal insufflation in overcoming the
collapse of the lungs, following upon the resection of the chest
walls, has been amply confirmed by my colleague. Dr. F. W.
Parham, whose able and exhaustive monograph on the " Surgical
Treatment of Tumors of the Chest Walls '' is familiar to all
those who have followed the latest developments in this field
of thoracic surgery. The interesting case just reported by our
distinguished fellow, Dr. Keen, also illustrates the practice of
pulmonary insufflation to overcome the collapse of the lung in
traumatic pneumothorax; but the form of apparatus used — i. e.,
the Fell mask, by which air is insufflated by the oro-nasal
method — is liable to failure, chiefly from the dropping of the
tongue backward and the introduction of air into the pharynx
instead of the air passages, and is, therefore, unreliable as a
surgical method, more especially in critical conditions, in which
certainty and precision are absolutely necessary. That in this
396 MATAS,
case (Dr. Keen's) the collapse of the lungs which followed the
entrance of air into the pleura would have been promptly over-
come if an intralaryngeal canula had been used, as in Dr. Par-
ham's case, cannot be doubted. The recovery of the patient and
the absence of untoward symptoms when the pleura was opened
simply illustrate the fact that in this, as in other recorded cases,
acute surgical pneumothorax does not invariably cause an arrest
in the respiration in both lungs ; but in man, more often than
in dogs and other lower animals, there is often a tolerance to
the invasion of the pleura with air, provided the air is allowed
to enter and fill the pleura gradually. This toleration of pul-
monary collapse in some cases does not argue that the occur-
rence of this condition is free from peril ; on the contrary, the
numerous cases that have been recorded (see author's contribu-
tion to the surgery of the chest^) only confirm the experimental
evidence which conclusively demonstrates that the sudden ad-
mission of air in the pleura through q^large fenestrum is one of the
greatest danger elements in intrathoracic surgery and one of the
most serious obstacles in the advancement of surgery of the chest.
It would now appear from all that has been said and done
that no further discussion could be called for, at least on the
value of a reliable apparatus for maintaining artificial respira-
tion in the course of intrathoracic operations. But a little
thought and experience in this field will convince us that the
application of artificial respiration by mechanical devices as
applied to surgical conditions is still in its infancy, and that the
clinical applications of intralaryngeal insufflation thus far made
have been to a large extent empirical and justify further experi-
mentation with the view of elevating this mode of treatment to
a higher plane of scientific accuracy.
There are also certain conditions met in surgery which differ
radically from the conditions met in purely medical cases, and
it is with a view of adjusting our resources to these more effec-
tively that I have continued to devote much time and thought
to the mechanical features of the subject.
1 Transactions of the Louisiana State Medical Society, 1899.
ARTIFICIAL RESPIRATION WITH AN O DWYER TUBE. 397
In order to investigate with any degree of accuracy the effects
of pulmonary insufflation by the intralaryngeal method upon
the lungs in normal and pathological conditions, the first requi-
site was a suitable apparatus which would indicate the positive
and negative variations in the intrapulmonary pressure during
insufflation (inspiration) and expiration, and that would also
provide a measure and means of controlling the quantity of air
injected into the trachea.
It was evident from the start that the bellows provided with
the original Fell-O'Dwyer and their modifications by Dr. Bloom
and myself, or by the Doyen instrument, could not be utilized
for the purpose, and that an entirely new apparatus, based upon
the principle of the pump, would have to be constructed for our
experiments. As a result of many trials with different models
and suggestions the machine which is shown in Figs, i and 2,
and described as an " experimental automatic respiratory appa-
ratus," was adopted. In the construction of this apparatus, as
well as in devising the sequel of this, which is our practical and
latest improved single cylinder pump for clinical use (see Figs.
3 and 4), I have had the benefit of the collaboration of my
assistant and friend. Dr. John Smyth, whose training and skill
as a mechanical and civil engineer have been most helpful in
overcoming the mechanical obstacles met in perfecting the
working details of these appliances.^
The idea of utilizing an automatic respiratory apparatus on
the duplex principle, with independent inspiratory and expira-
tory cylinders or pumps, was suggested by some of the older
appliances devised for this purpose, and especially by the desire
to test Doyen's method of artificial respiration with his com-
pound inspiratory and expiratory bellows. The evident object
of this machine was to simplify the work of the operator
in applying artificial respiration to a purely mechanical func-
tion, so that once the intralaryngeal canula was adjusted in
situ the work of insufflation and expiration would be carried
1 My thanks are also due to the McDermott Surgical Instrument Company of New
Orleans, who manufacture this instrument! for their valuable co-operation and interest
in this work.
398 MAT AS,
on automatically by the machine. As will be seen by looking
at Figs. I and 2 and the accompanying legends, which describe
the details of our experimental duplex apparatus, pump I, on
backward stroke, aspirates fresh or oxygenized air through the
inlet valve (IV), and during forward stroke insufflates it into
the lungs through the opening in the cut-off (V). Pump A, on
backward stroke, aspirates the vitiated air from the lungs
through cut-off valve (V), and in forward stroke discharges it
through outlet valve (OV). The mechanism by which this
alternate insufflation and aspiration is due is clearly explained
by the legends and by the separate diagram of the cut-off.
The pumps in this machine were made to work independently
of each other, or could be worked together if desired, and were
connected with a manometer which accurately indicated all the
variations in the intrapulmonary pressure during inspiration
and expiration. The stroke-length of the piston in both pumps
regulated the capacity of the cylinders, and this in turn was
controlled by an adjustable screw and collar. The central
piston rod, which moved the cut-off valve, was marked into
spaces of one inch each, equivalent to about 4.4 cubic inches of
air per inch, as determined by spirometric tests. The total
maximum capacity of these experimental cylinders was nearly
1500 c.c, or 90 cubic inches, corresponding to the average
total respiratory capacity of a single lung in repose (Landois).
The quantity of air insufflated and the intrapulmonary press-
ure could be rhultiplied indefinitely by excluding the aspirating
cylinder (A) and preventing the escape of air from the trachea
while working the inspiratory cylinder (I). The need of a
powerful pump that would permit of an indefinite increase in
the intrapulmonary pressure suggested itself in view of our
desire to test the resistance of the lung tissue to pathological
pressure and to determine the amount of air and the pressure
required to produce emphysema, laceration of the lungs, and
other pulmonary lesions by violent insufflation.
When the large duplex pump had been completed it was
utilized in our preliminary experiments on dogs and human
cadavers to familiarize ourselves not only with the technique
ARTIFICIAL RESPIRATION WITH AN O DWYER TUBE. 399
of insufflation, but to test the practicability of automatic respira-
tion in which the cyUnders were used to alternately pump air
into and out of the lungs. But we soon found out that there
were many serious obstacles in the way of the successful appli-
cation of this duplex principle, and the most important of these
was the damage done by the suction force exercised by the
aspirating cylinder in expiration. The aspiratory action of
cylinder (A) caused a collapse of the smaller bronchial tubes,
which are not sufficiently cartilaginous and rigid to resist even
moderate, slow aspiration. We found that when inspiratory
pressure on insufflation was equal to +10-14 mm. mercury,
the negative pressure or expiration was — 20-24 mm., as gauged
by the manometer. The respiratory movements, under these
circumstances, were carried on at the rate of sixteen times per
minute, and yet, under these conditions, a general collapse of
all the smaller bronchi took place in both lungs, which impris-
oned the vitiated air over large areas with each expiration.
Under these conditions the bronchi are opened again with each
insufflation, but the deoxygenized air is not completely released,
and thus accumulates in the air-cells, thereby increasing the
intra-alveolar tension to such an extent that it arrests the capil-
lary circulation, and thus defeats the essential purpose of the
mechanism. If the suction force is still increased by increasing
the frequency of the respiratory rhythm, then a vacuum is cre-
ated in the larger bronchi as well, which, when frequently
repeated, induces a condition of hyper^emia, paresis of the ves-
sels and oedema of the mucosa, followed by extravasations
which permanently damage the lung and still further cripple
its respiratory function. This we found to be the case in the
lungs of the dog upon which we performed our first experi-
ment, and the lesions were plainly recognizable during life and
after death. The evidence obtained in this experiment promptly
led us to abandon all expectation of ever utilizing this duplex
method in practice.
It is fortunate, in view of the dangers attending the use of
the compound inspiratory and expiratory machines — which for
convenience we shall continue to designate as the " duplex "
400 MATAS,
machines that the expiratory part of the respiration aid is
unnecessary in practice, and that all that is required, as far as
the expiration is concerned, is that the apparatus used shall in-
sufflate air into the lungs in sufficient quantity and under proper
pressure. As stated by O'Dvvyer in his commentary upon the
original Fell apparatus, all that is required is to get air into the
lungs and give it sufficient room to expand and time to escape,
the power generated and stored up in overcoming the resist-
ance to inspiration being amply sufficient to carry on expiration.
The correctness of this statement is well borne by practical
experience with the Fell-0'Dwyer apparatus, and is fully con-
firmed by our experiments ; but the dangers which attend arti-
ficial expiration, or, rather, aspiration, had not been appreciated
by previous experimenters, if we are to judge by the existence of
various apparatus, notably the ingenious device of Doyen, which
have been created for the purpose, but evidently never utilized
in practice.
After demonstrating to our satisfaction that the double inspi-
ratory and expiratory pump was not a practical appliance for arti-
ficial respiration, we abandoned the aspirating cylinder entirely
in our work and utilized the single insufflating cylinder (I, Figs, i
and 2), on the O'Dwyer principle, and, having found it perfectly
reliable, have made it the basis of our practical clinical respira-
tory machine shown in Figs. 3 and 4. Without entering into a
tedious and unnecessary description of our experiments with
this pump on human cadavers and dogs, we shall simply make
a few statements which will serve as conclusions to our work,
which is still incomplete, but is quite sufficient to satisfy us of
the practical working qualities of the apparatus which is now
exhibited to you. (Figs. 3 and 4.)
These experiments confirm the conclusions already established
by the investigations of the physiologists (Bonders, Landois,
etc.) and of the surgeons (Tuffier and Hallion), to the effect that
the intrapulmonary pressure required to overcome the elastic
retractility of the lungs when collapsed by the admission of
air into the pleura is very slight, and that positive pressure of
6-8 mm. mercury is quite sufficient.
ARTIFICIAL RESPIRATION WITH AN ODWYER TUBE. 4OI
In a human adult cadaver, with both sides of the thorax widely
opened by two quadrilateral fenestra (4x5 inches), the lungs, normal
and free from adhesions, were insufflated with the respiratory pump,
the modified O'Dwyer canula (M. F., Fig. 3) being introduced into
the trachea. The stroke of the piston was set at 6^ inches (^ about
28 cubic inches of air per stroke), the manometer indicating+io mm.
pressure. With each stroke the completely collapsed (normal) lungs
were made to expand and project beyond the line of the chest wall.
In the same subject, with a 4}4-inch stroke (19 cubic inches air dis-
placement), the manometer indicating + 8 mm. pressure, the lungs
were fully expanded and held against the chest wall.
Same subject, with a 4-inch stroke (=17.6 cubic inches) and a press-
ure of -f-6 mm. mercury, the lungs were expanded, but barely touched
the ribs.
In another cadaver, adult, male, preserved in a refrigerator four
weeks, insufflation was tried with the same pump without opening the
chest. Our pump working with a 10^ -inch stroke (= 45 cubic inches
of air displaced with each stroke) and the manometer indicating 10 mm.
mercury, the cadaveric rigidity of the diaphragm and the chest was
overcome and the chest expanded with marked bulging at the inter-
costals and epigastrium. In this way the cadaver was made to breathe
rhythmically at the rate of eighteen to twenty times per minute.
A pressure of 8 mm. mercury was found to be quite sufficient to
expand the lungs in another adult male subject upon which we experi-
mented twelve hours after death. In this case the cadaveric rigidity
was less, and the expansion of the chest, produced by a full inspira-
tion, was easily obtained with a displacement of 45 inches per stroke of
the pump.
The following experiment on a dog was also instructive.
A medium size mongrel cur was anaesthetized with chloroform by the
usual oro-nasal method ; after relaxation had been obtained the intra-
laryngeal canula was introduced into the glottis, and chloroform was
continued through the canula until anaesthesia was complete. The fun-
nel of the inhaler was then attached to the inlet of the insufflating
pump, and the insufflating pump was set so that each stroke of the pis-
ton displaced 45 cubic inches per stroke. A large osteoplastic thorac-
otomy was performed, and the right pleura was rapidly exposed by
cutting a large quadrilateral flap measuring 4x5 inches. The bleed-
Am Surg 26
402 MAT AS,
ing from the intercostals was surprisingly small. The lung immedi-
ately collapsed, and respiration ceased at once. The pump was then
set into operation at the rate of about eighteen times a minute. The
lung immediately expanded to the full limit of the chest wall, showing
a tendency to prolapse through the fenestrum. With aspiration (the
aspirating cylinder being used) the lung receded as in expiration, and
the rhythm of the respiration was kept up for over four minutes, dur-
ing which the circulation was restored and the animal appeared to
recover from the shock. During this time the demonstration of the
efficacy of insufflation could not have been more satisfactory or con-
clusive. We were able to manipulate the lung freely while it was alter-
nately expanding and contracting, and had no difficulty in reaching
the hilum of the organ and feeling it as well as the pulsating heart and
great vessels. If we had then closed the chest we believe the animal
would have survived the ordeal ; but we were curious to try the suture
of the lung and other surgical procedures, and while preparing to do
this we observed that the expiratory retreat of the lung became more
feeble and that the lung failed to empty itself. This we attributed to
the powerful suction of the aspirating cylinder, which interfered with
complete expiration by creating too great a vacuum in the bronchi.
While observing this phenomenon the animal became cyanosed and the
heart's action feeble and irregular. In the meantime the assistant in
charge of the canula accidentally allowed this to become displaced, and
the air was pumped into the oesophagus, causing an enormous distention
of the stomach, which still further interfered with the action of the dia-
phragm. Before this accident could be remedied the animal died. It
was plain to all that if in this case only the single insufflating cylinder
had been used, or that the aspirating cylinder had been promptly dis-
connected and expiration allowed to take place through the canula,
that death would not have occurred.
The fact remains, however, that insufflation did very promptly over-
come the collapse of the lung which followed, with arrested respira-
tion, the moment the pleura was widely opened. It is also positive
that the animal would have perished promptly when this happened
had not the insufflation immediately revived him by restoring the
respiration.
Other experiments were performed to test the amount of press-
ure required to destroy the elasticity of the lungs and to produce
emphysema by rupture of the air cells, and while these are still
ARTIFICIAL RESPIRATION WITH AN O DWYER TUBE. 4O3
incomplete we believe it safe to assert that as long as the intra-
pulmonary pressure of the air insufflated is not sufficient to cause
the lung to be herniated beyond the chest wall, there is no seri-
ous risk of traumatic emphysema in intrapleural operations. In
fact, we have been struck in our experiments on the cadaver and
dog by the enormous resistance of the lung tissue to laceration.
The lung apparently recovers promptly, even its normal respira-
tory capacity is doubled. In a dog of medium size from looo
to 1500 c.c. were required to cause serious permanent emphy-
sematous lesions. Further experimental evidence is still required
to study the exact conditions under which these pathological
lesions are produced. It is also quite possible that minute his-
tological lesions are caused by even moderate over-distention
which has escaped the gross, naked-eye observations which we
have made.
The most important part of our work still remains to be com-
pleted, and that is the practical experimental study of pulmo-
nary and mediastinal surgery under the new conditions of aided
respiration. That much can be learned in this field by repeat-
ing in a systematic way many of the older experiments of Bloch,
Marcus, Schmid, Biondi, Willard and others, cannot be denied.
In the meantime the means of applying artificial respiration with
an apparatus which can be readily and safely applied, which
will accurately register the intrapulmonary pressure during
insufflation, and will permit the operator to regulate the quantity
of air insufflated, is necessary for experimental work and is very
desirable in actual practice. Without wishing to disparage or
minimize in the least the excellent service which the Fell-
O'Dwyer apparatus and its modifications have rendered and are
capable of rendering in medical practice, we believe there is a
place for such an apparatus as I now have the pleasure of sub-
mitting to you. The chief objection to the bellows as an insuf-
flating agent is that its insufflating capacity cannot be regulated
or graduated, and that it is capable of insufflating at best only
a fixed quantity of air. We have tested all the bellows now in
use for the purpose (original Fell, Fell-0'Dwyer, and its modi-
fication by Dr. Bloom), and these are capable of a maximum
404 MATAS,
displacement of 45 cubic inches of air. While this quantity is
far in excess of that required to overcome the elastic retrac-
tility of the collapsed lung when the chest is opened (28 cubic
inches being amply sufficient in healthy lungs), the empirical
insufflation of the excess of air discharged by the bellows is
not excessive or injurious when artificial respiration is practised
on the closed chest with a pressure of 6 mm. in cases of arrested
respiration. The more serious objection to the bellows is that
it is incapable of sustaining intrapulmonary pressure long enough
during the periods of inspiration (insufflation) to favor surgical
action in open cases. The bellows will distend the lungs fully
when the respiratory movements are kept going at the rate of
20 insufflations per minute ; but whenever this rhythm is mod-
erated in frequency to 10 or 12 complete respirations per min-
ute or less, the lungs empty themselves before the next insuffla-
tion is ready to fill them again. This is caused by a backward
leakage into the bellows, while the finger which controls the
outlet of the laryngeal canula continues to stop the opening.
In other words, the duration of the inspiration cannot be con-
trolled by the will of the operator. With our pump, on the
other hand, the pulmonary distention obtained by the inspira-
tory insufflation is not lost by leakage, and is sustained as long
as the expiratory outlet in the canula is stopped by the thumb
of the operator. In this way the rhythm of the respiration can
be regulated by the operator, which is a distinct advantage in
operative work.
The difference in the action of the pump and bellows is in this
respect well shown by a simple demonstration with the artificial lungs
that we have extemporized for the purpose. The model which I now
show you has been made by attaching a pair of rubber toy balloons to
a human larynx and trachea. The balloons are connected separately
to each one of the primary bronchi, which remain as a part of the
bifurcation. If we now intubate the larynx with the O'Dwyer canula
and insufflate with the bellows you will see that the balloons become
distended to their full capacity, but this distention is followed by an
immediate collapse, which begins before 1 have time to compress the
bellows again. This happens in spite of the fact that I have theexpira-
ARTIFICIAL RESPIRATION WITH AN o'dWYER TUBE. 4O5
tory outlet in the laryngeal canula closed. As the connections are all
air-tight, it is evident that there is no exit for the air in the lungs except
through the bellows. If the same experiment is repeated with our
pump you will see that the balloons remain distended fully until I
release the confined air by withdrawing my finger from the outlet in
the canula.
If we now summarize the peculiarities of this apparatus for
artificial respiration (see Figs. 3 and 4) we will state —
1. That it is a graduated pump which can be readily adjusted
to any quantity of air required from i to 700 cm, (or i to 43
cubic inches).
2. That it is provided with a mercurial manometer, which
indicates the intrapulmonary pressure and is an index to the
peripheral resistance that is overcome by the insufflation.
3. That it is provided with an automatic cut-off which effec-
tively prevents any backward leakage of air into the cylinder,
and thus puts the inspiratory inflation of the lungs under the
control of the operator, thus regulating the duration of the
inspiratory act and thereby the rhythm of the respiration.
4. It is provided with an air filter interposed between the
larynx and the pump, which purifies the air injected through
the pump.
5. The inlet opening of the pump can be readily adjusted to
a screened funnel and tube for further administration of chloro-
form or oxygen while artificial respiration is going on.
6. It is provided with an intralaryngeal canula of the O'Dwyer
type, with several adjustable conical tips for intubation. Our
modified canula differs from the O'Dwyer canula in the shape
of the handle, which is pistol-shaped and gives a firm grip, and
in having an opening guarded with a stopcock which is easily
connected to a tube and funnel for the administration of chloro-
form while the patient is breathing through the intubating
canula. While insufflation is going on the stopcock is closed
and the anaesthetic is administered through the inlet in the
pump.
In applying this apparatus the intubating end of the canula is
introduced into the space above the vocal cords bounded by
406 M A T A S ,
the aryteno-epiglottic folds and epiglottis. In some cases the
smaller conical tips may be introduced as an ordinary intu-
bating canula between the vocal cords ; but in the majority of
cases this is unnecessary, as the conical graded tips furnished
with the original O'Dwyer canula can be accurately adjusted to
supraglottic space, where it is firmly held in place by the epi-
glottis, the arytenoids, and the aryteno-epiglottic folds. The
adjustment of the intralaryngeal tips requires a certain experi-
ence and dexterity, which are generally obtained after a few
attempts, but are better acquired by a preliminary experience
on the cadaver. The long handle and firmness of the metallic
canula greatly facilitate the manoeuvre required in fitting the
intubating tips to the glottic opening. In this respect the
O'Dwyer canula is easier to handle and to adjust than the
short intralaryngeal tube devised by Doyen, which requires for
its introduction the special long forceps which he has devised.
In applying intubation for insufflation the preliminary anaes-
thesia of the patient is required, unless he be already uncon-
scious and anaesthetic from the effects of asphyxia, shock, or
narcotic poisons. After the patient is relaxed by the anaes-
thetic the introduction of the intralaryngeal canula is much
simplified. Once the canula is in place it may be necessary to
continue the anaesthesia. This can be very readily done by
attaching the funnel-shaped inhaler to our canula. In the
meantime the connections with the respiratory cylinder are
adjusted and kept in readiness for insufflation the moment the
operator may deem it necessary. When the pump is set in
operation the stopcock which guards the opening of the inhaler
is closed in order that the insufflated air may not escape through
the inhaler. The inhaling-tube and funnel are then transferred
and attached to the inlet of the pump itself, so that anaesthesia
may be continued if desired while artificial respiration is going
on. It is also a very simple matter to attach the discharging
tube of an oxygen cylinder to the inlet of the pump if the use
of this gas be especially indicated. In using the pump on
adults it will be well to adjust the piston so that the full capacity
of the pump (43 cubic inches) be administered in the start, after
ARTIFICIAL RESPIRATION WITH AN o'dWYER TUBE. 407
which the quantity of air may be regulated according to the
effect observed on the lung itself in open cases or on the chest
walls and diaphragm when the chest is closed, as in non-surgi-
cal conditions. If the amount of air insufflated is excessive
the lung will have a tendency to become herniated through the
opening made in the chest walls, and the. capacity of the pump
should be regulated by the screw and collar on the piston until
the proper distention is obtained — i. e., just enough to make
the lungs touch the chest wall in full inspiration. The normal
pressure required to obtain this pressure is 6 to 8 mm., as indi-
cated by the manometer. . The manometer is especially useful
in indicating cumulative or excessive pressure in the lungs,
more particularly in closed cases. It will help to regulate the
rhythm of the respiration and to prevent too rapid or frequent
insufflations, which would overstretch the alveoli and thus
defeat the purpose of the insufflation, a pressure of 30 or more
mm. being sufficient to stop the aerating function of the lungs,
the manometer in this and other ways being quite a useful
adjunct to the apparatus.
In applying artificial respiration with this pump (which will
only open or close with the full excursion of the piston), it will
be found that the respiratory movements will be carried on with
a regularity, fulness, and deliberation that are scarcely possible
with the bellows. The duration of each inspiratory insufflation
will be controlled by the finger of the operator which closes
the outlet in the handle of the canula. As long as the thumb
occludes this outlet the insufflated air will be retained in the
chest and the distention of the lung will be maintained. It is
only when the thumb is lifted from the opening that the im-
prisoned air in the lungs escapes and that expiration takes
place. In this way the rhythm of the respiration can be regu-
lated, so that it may be very rapid or slow according to the
needs of the case.
We regret very much that the opportunity has not yet pre-
sented itself to apply this pump on the living subject, but
our experience with it on the cadaver and dog fully demon-
strates its practical working capacity. In submitting this appli-
408 MATAS,
ance to the Association we do not pretend to have reached the
ideal apparatus ; on the contrary, we do not doubt that in the
course of further experimentation other suggestions may be
made which will contribute to its simplicity and usefulness.
It is the outcome of our efforts in meeting the necessities of
experimentation, and in the hope that it may prove useful to
other investigators and surgeons who are interested in the
development of a most promising field of surgical advancement,
we gladly submit it to the profession.
EXPERIMENTAL AUTOMATIC RESPIRATORY APPARATUS,
WITH INDEPENDENT INSPIRATORY AND EXSPIRATORY CYLINDERS OR PUMPS, FOR
THE PURPOSE OF MAINTAINING RHYTHMICAL ARTIFICIAL RESPIRATION.
Pump I, on backward stroke, aspirates fresh or oxygenized air through inlet valve IV,
and during forward stroke insufflates it into the lungs through opening in cut-off V.
Pump A, on backward stroke, aspirates vitiated air from lungs through cut-off valve V,
and on forward stroke discharges it through outlet valve OV.
LEGEND TO FIGS. I AND 2.
H. Handle common to P and the two pump pistons.
P. Accessory piston for automatic cut-off.
S. Sliding tube for automatic cut-off.
A. Aspirating pump.
I. Inspirating pump.
C. Adjustable collar for automatic cut-off and regulating stroke.
IV. Inlet valve for o.\ygenized or medicated air.
L. Compound lever for automatic cut-off.
V. Valve or stopcock for automatic cut-off.
OV. Outlet valve for discharge of respired air.
F. Stopcock to disconnect pump A.
R. Rubber tube to intubating apparatus.
T. Glass T connecting manometer tube.
SR. Small rubber tube connecting with manometer.
MF. Modified O'Dwyer intubating apparatus, with thumb opening closed with rubber
stopper.
M. Mercurial manometer, reading in millimetres to 200, pressure or vacuum.
Notes.
To allow the double yet independent action of these pumps an automatic cut-off was
necessary. This was accomplished by the modified stopcock V attached by the com-
pound lever L to sliding tube S, which was moved by the accessory piston-rod P attached
to the common handle H. This piston P, having a knob on its free end, travels in S,
Fig. I.
Fig. 2.
Experimental Automatic Respiratory Apparatus with Double Inspiratory and Expiratory Cylindtrs.
ARTIFICIAL RESPIRATION WITH AN o'dWYER TUBE. 4O9
and when about one and a half inch from limit of forward stroke it strikes the end of
the tube, driving it forward and pushing the lever of stopcock V through arc of 90° (see
Fig. I and dotted line in diagram), thus closing communication of pump I with tracheal
tube R, and opening communication of R with pump A.
INSPlRATING PUMP
IV
r^^
1
U
INL
^^
\-:
,-'-
INLET FLAP VALVE
OUTLET FLAP VALVE
wrTH GOIL SPRING
In the sliding tube S, almost its entire length is a slot ; on the tube is an adjustable
collar C with a thumbscrew to clamp it at any point ; in this collar and projecting through
the slot is a screw against which the knob of accessory piston P strikes when within one
and a half inch limit of backward stroke ; this final one and a half inch of stroke then
moves the tube S which causes cut-off at V as before, but in opposite direction, closing
communication of pump A with tracheal tube R and opening communication between
tracheal tube and pump I. (See diagram.)
4IO
MATAS.
APPARATUS FOR ARTIFICIAL RESPIRATION IN SURGICAL AND
MEDICAL PRACTICE (LATEST MODEL),
WITH AUTOMATIC CUT-OFF AND ATTACHMENT FOR GOVERNING STROKE OF
PUMP AND REGULATING AMOUNT OF AIR INSUFFLATED.
Pump A, on backward stroke, receives fresh or medicated air through opening at I,
and during forward stroke insufflates it into lungs through opening in cut-off V. Ex.
piration is accoraphshed through opening in modified O'Dwyer intubation canula by
operator removing thumb from outlet O.
LEGEND TO FIGS. 3 AND 4.
H. Handle common to P and the pump piston.
P. Accessory piston for automatic cut-off.
S. Sliding tube for automatic cut-off.
C. Adjustable collar for automatic cut-off and regulating stroke.
I. Inlet for fresh or medicated air.
L. Compound lever for automatic cut-off.
V. Valve or stopcock for automatic cut-off.
F. Cylinder containing absorbent cotton for filtering air.
R. Rubber tube to intubating apparatus.
T. Glass T connecting manometer tube.
SR. Small rubber tube connecting with manometer.
MF. Modified O'Dwyer intubating canula and stopcock attachment for chloroform
anaesthesia.
M. Mercurial manometer, reading in millimetres to sixty, pressure or vacuum.
Notes.
To obviate the use of flap or ball valves which present a considerable factor of uncer-
tainty, an automatic cut-off with positive stopcock was adopted (Dr. Smyth's sugges-
tion). The modified stop-cock V attached by the compound lever L to the sliding tube
S is moved by accessory piston P attached to the common handle H.
PUMP CYLINDER
The piston P, having a knob on its free end, travels in S, and when ^^„ inch from
limit of forward stroke it strikes the end of the tube, driving it forward and pushing the
Fig. 3
Fig. 4.
Latest Working Model of Apparatus for Artificial Respiration in Medical and Surgical Practice.
ARTIFICIAL RESPIRATION WITH AN O DVVYER TUBE. 4II
lever of the stopcock V through arc of 45° (see Fig. 3, L, and dotted line in diagram),
thus closing communication of pump with tracheal tube and opening communication
with I.
In sliding tube S almost its entire length is a slot, on the tube is an adjustable collar C
with a thumbscrew to clamp it at any point; in the collar and projecting through the
slot is a screw against which the knob of the accessory piston P strikes when within ^^
of an inch of limit of backward stroke, thus moving the tube S which causes cut-off at
V as before, but in opposite direction, closing communication of pump with inlet I and
opening communication with tracheal tube (see diagram).
The sliding tube S is graduated on each side of the slot, on left side in cubic inches to
45, and on right side cubic centimetres to 700, relative to pump capacity.
Filter F is one and a half by two and a quarter inches, filled with absorbent cotton to
prevent oil or other no.xious materials from entering tracheal tube.
Vaseline has been used in pump instead of sperm or cylinder oil, it having no odor.
Manometer M is made of one-sixth inch glass tubing on the open principle.
Intubation canula differs from the O'Dwyer canula in (i) the shape of the handle
which forms the grasp of the instrument, while the thumb of the operator controls the
expiratory outlet; (2) in the addition of an attachment and stopcock for a chloroform
inhaler of the Trendelenburg funnel type. In this way anaesthesia can be continued or
interrupted while the canula is in the larynx. As long as artificial respiration is not
required the chloroform is administered directly through' the canula inhaler ; when the
pump is in operation the anaesthetic attachment is removed, stopcock closed, and in-
haler attached to pump-inlet I.
The pump is made of one-sixteenth inch copper tubing two and one-half inches in
diameter and ten and one-half inches long, having total effective capacity of 43 cubic
inches, 700 cubic centimetres, with nine and eight-tenths inches stroke, or 4.388 cubic
inches capacity per inch of stroke.
AN APPARATUS FOR MASSIVE INFILTRATION
ANESTHESIA WITH WEAK ANALGESIC
SOLUTIONS (MODIFIED SCHLEICH
METHOD).
By RUDOLPH MATAS, M.D.
NEW ORLEANS, LA,
In a paper on " Local and Regional Anaesthesia," published
in the Philadelphia Medical Journal, November 3, 1900, I de-
scribed and illustrated a simple apparatus which I had used
extensively since March, 1900, in the practice of local and
regional anaesthesia, with weak solutions, by the Schleich
method.
The advantages of an injecting-bottle, by which the anaes-
thetizing solution could be forced (by pneumatic pressure) in
large quantities into the tissues continuously and without ne-
cessitating the frequent interruptions caused by refilling even
large antitoxin syringes, occurred to me while applying subcu-
taneous gelatin injections in the treatment of inoperable aneu-
rism by Lancereaux's method. After a few trials of the new
device I abandoned the syringes and substituted the apparatus
described in the article referred to. It consisted essentially of
two parts. One, a strong graduated glass nursing-bottle (8-ounce
capacity) and a pump, the ordinary pump of a Potain aspi-
rator, with the necessary rubber tubing and metallic connec-
tions, by which air could be forced into the bottle. The bottle
was provided with the perforated rubber stopper holding the
metallic Y tube of the Potain bottle, which was held firmly in
the bottle by a special metallic clamp and collar, which pre-
vented the stopper from being blown off by the compressed air
Fig. I.
Apparatus for rapid, massive infiltration anaesthesia. Charging the cylinder with air pump.
(Dr. Matas.1
Fig. 2.
Cylinder charged and inverted. The pumping outfit is detached when the apparatus
is in operation.
APPARATUS FOR INFILTRATION AN/ESTHESIA. 4I3
in the bottle. The bottle was charged with the pump until the
resistance felt in the piston indicated that the limit of pneumatic
compression had been reached. Usually ten to twelve pump-
ings with the Potain pump sufficed to charge the bottle suf-
ficiently to force the contents out of the bottle until this has
been completely emptied. After charging the bottle the pump
was disconnected, and the charged reservoir remained in the
hands of the assistant, who held it while the operator directed
the flow of the anaesthetizing solution by means of the needle
and discharge tube. The flow of the fluid was perfectly con-
trolled by the stopcock at the Y tube.
I utilized this simple and easily improvised contrivance in a
very extensive series of minor and major operations, and would
still continue to use it had it not been that in consequence of
repeated accidents caused by the breaking of the bottle, I real-
ized that a strong metallic receptacle was necessary. I found
that in dealing with dense and especially chronically inflamed
tissues the pressure required to force the fluid into the tissues
subjected the bottle to a dangerous strain, causing explosions,
especially when the charging of the bottle was intrusted to
inexperienced assistants.
The bottle under these circumstances would break into frag-
ments, which would have cut the hands of the assistants had
not the precaution been takeato wrap the bottle in sterile gauze.
In addition to the dangers of this occurrence, the delays
caused by refitting another bottle were very annoying. After
the third accident of this kind had occurred I began to experi-
ment with various metallic bottles, and after a number of trials
I finally concluded to adopt the model shown in Figs, i and 2.
The receptacle consists of a polished copper cylinder, nickel-
plated on its outer and inner surfaces, measuring 20 cm. (8
inches) in circumference and 14 cm. (5|^ inches) in length. The
top is provided with a metal T-tube, allowing the air to enter
and the fluid to escape, both ends of the T being provided with
stopcocks. The actual capacity of the cylinder is 13 ounces
(nearly 400 c.c). but only lo ounces (300 + c.c.) of fluid are used
to allow sufficient space for the air charge. The cylinder has
414 MATAS,
been tested to stand 147 pounds of internal hydrostatic press-
ure per square inch, and when the attachments are screwed on
it is absolutely water-tight under the highest pressure. The
fluid is introduced into the receptacle through the bottom,
which is closed by a brass nickel-plated cover, made to screw
tightly over a rubber washer into the cylinder. The bottom is
also provided with two pinions, which favor the grip of the
fingers in screwing it to the cylinder. These are not essential,
however, as the bottom piece screws on easily to the cylinder.
A glass water-gauge, protected by a graduated metal case, is
fixed to the cylinder to allow the operator or the assistants to
keep account of the amount of fluid used as the operation pro-
gresses. This gauge is a very important part of the apparatus,
and can be easily detached for aseptic purposes. The pumping
outfit consists of a small bicycle hand-pump, the smallest made;
it is 13 cm. (5^ inches) in length and 7 cm. (nearly 3 inches)
in circumference, and is very cheap (costing only 15 cents).
This is attached to a small metallic cylinder, 7^ cm. (3 inches)
in circumference by 5^ cm. (2^ inches) in length, which is
filled with sterile absorbent cotton, and is used as a filter for the
air injected into the reservoir.
After the sterilized solution has been placed in the receptacle
this is charged with air until marked resistance is felt in driving
the piston, when the attachments to the filter and pump are
unscrewed, and the apparatus is ready for infiltration. The
needles used for injecting are of various sizes, lengths, and
curves ; eight are provided with the outfit varying in size and
calibre from a fine hypodermic syringe (for intradermal work)
to a large 7 cm. needle (Dieulafoy, No. 2), which is used when
the rapid cedematization of large areas is required. The rubber
tubing connecting the apparatus to the injecting needle is 38
cm. (a little over 15 inches) long, to give the necessary freedom
of movement to the operator in handling the needle. The rub-
ber tubing is the most perishable part of the apparatus, as the
rubber is easily damaged by prolonged and repeated steriliza-
tion. As this tube is intended to convey only the sterile fluid
it is unnecessary to subject it to long sterilization, and usually
APPARATUS FOR INFILTRATION ANESTHESIA. 415
an immersion of three minutes in boiling water, followed by a
bath in a formalin solution, i per cent., suffices to make it per-
fectly safe from the aseptic point of view, without seriously
impairing the elastic qualities of the rubber.
The chief advantages claimed for this apparatus over the ordi-
nary syringes used for infiltration anaesthesia are: (i) That it
allows the operator to infiltrate and cedematize large areas
rapidly, continuously or interruptedly without the delay caused
by recharging or exchanging syringes ; (2) that by the use of
long needles it tends to diminish the traumatism caused by fre-
quent punctures made necessary by the shorter needles used
with the ordinary quickly exhausted syringes.
The rapidity with which the solution is forced into the tissues
as well as the thoroughness with which this is done is surpris-
ing. In addition to this the limited number of punctures
required to infiltrate a very large area, sometimes one or two
punctures being sufficient when a fine 7 cm. needle is used,
greatly diminishes the traumatism of the tissues and enor-
mously expedites the work.
The contrast between this method and the older, in which
the ordinary hand-syringes of small capacity are used, is agree-
ably apparent, and will be readily appreciated by anyone who
has been operating by the classical methods. Since I have
adopted the present method I have obtained far more satisfac-
tory results in extensive operations, and have used Schleich's
weaker No. 3 (i/ioo of i per cent.) with much greater success; in
fact, I have learned to rely on infiltration alone — z. ^., depending
chiefly upon the physical rather than the chemical effects of the
solution than formerly. The solutions used in my practice at
present are 1/5, i/io, 1/20 and i/ioo of eucain B., dissolved in
8/10 of I per cent. sod. chlorid. solution (Heinze), sterilized by
boiling. The 15 of i per cent, solution is used for the intrader-
mal injection — the weaker solution for the subcutaneous areas.
The solutions are injected tepid or cold into the tissues ; after
the infiltration is completed the entire field is covered with a
sterile ice-bag for three or five minutes, which, by refrigerating
the solution, greatly intensifies the anaesthetic action.
4l6 APPARATUS FOR INFILTRATION ANSTHESIA.
The details of the methods and their applications, according
to the indications furnished by the special tissues involved and
the pathological conditions encountered in the tissues, have
been detailed in the contribution referred to published by me
(loc. cit., Nov. 3, 1900). Since that time my experience has
widened very much, and I have improved constantly in the
technique as my experience has increased. It would be inter-
esting to describe some of the more exceptional cases in which
the possibilities of mas"sive infiltration have been tested, especially
in the major surgery of the face, neck, genito-urinary apparatus,
and extremities, but my purpose on this occasion is simply to
describe an improved apparatus, which, since December, 1900,
to the present date (May 7, 1901) has proved a most valuable
auxiliary in the prosecution of my anaesthetic work.
The apparatus has been manufactured for me by the McDer-
mott Surgical Company, of New Orleans, and is now sold by
them in a compact wooden case, which, in addition to the local
infiltration apparatus, has a complete outfit for spinal cocainiza-
tion, ethyl chloride spray, with space for the dry eucain B.
and cocaine tablets required in making the anaesthetizing solu-
tions. I am especially indebted to the manufacturers and to my
assistant, Dr. John Smyth, for valuable suggestions and other
assistance in completing the working details of the apparatus.
Since this article has been written I have read a contribution
by Dr. Ludwig Moszkowicz, assistant of Professor Gersuny,
Vienna {Cejitralblatt f. Chirurgie, No. 19, May 11, 1901), in
which he describes a glass bottle apparatus for Schleich infil-
tration anaesthesia.
This apparatus is practically an adaptation of the Potain
aspirator apparatus, and is in every essential point identical
with the contrivance described and illustrated by me in the
Philadelphia Medical Journal of November 3, 1900. I am
much pleased to find a confirmation of my ideas and results in
Dr. Moszkowicz's and Professor Gersuny's clinics, but believe
that the same objections which led me to abandon the glass
bottles for a metallic reservoir will also obtain in Vienna after
a more mature experience.
TWO CASES OF VICIOUS CIRCLE AFTER
GASTRO-ENTEROSTOMY.
BY THEODORE A. McGRAW, M.D.,
DETROIT, MICH.
The term " vicious circle " is applied by the Germans to
those pathological conditions occurring subsequent to gastro-
enterostomies in which the contents of' the stomach, instead
of following their proper course through the efferent portion
of the jejunum to the ileum, pass into the afferent limb of the
jejunum, and thence into the duodenum. If unrelieved, the
bile and other intestinal secretions and the ingesta will, after
distending the duodenum and adjacent jejunum to the utmost,
regurgitate into the stomach and, if not vomited, cause great
distention and pain, and hiccough, and finally cause death by
exhaustion. L had practised gastro-enterostomy over ten years
without meeting a case of this kind, when two cases in quick
succession aroused me to an appreciation of a danger which I
had come to regard as somewhat chimerical. I published a
summary of one of these cases in the New York Medical
Journal^ of June 26, 1900, in an article entitled ''Gastro-
enterostomy by the Elastic Ligature." The reason for its pub-
lication then was to show the effect of the elastic ligature as
illustrated by a post-mortem specimen. I wish now to publish
it in more detail in order to compare its history with that of
the second case, which followed so closely on its heels. In
recording both cases I shall omit, as far as possible, all such
details as may not seem relevant to my purpose, in order not
to weary my readers.
Am Surg 37
4l8 MCGRAW,
Case I. — A Canadian, aged thirty-one years, a patient of Dr.
Bryan, of Essex, Ontario, came to me with cancer of the pylorus.
His family history was bad. One sister had died of cancer of the
stomach, and another was then suffering with it. His disease had made
rapid progress. He had noticed it first in June, 1900, and in Novem-
ber it had caused nearly complete obstruction. I operated on
November 15, 1900, and made a gastro-enterostomy by means of the
elastic ligature. A transverse incision was carried from the median
line, 3 cm. above the navel, 10 cm. to the left, through the abdominal
wall. The jejunum was drawn up in front of the colon, turned so as
to bring the efferent portion to the right of and over the afferent por-
tion, and attached by the elastic ligature to the posterior wall of the
fundus of the stomach. The ligature included a length in the
stomach wall of about 5 cm. and about the same length in the wall
of the jejunum. On each side of the ligature for a distance of 6 or 7
cm. the serous coats of the two viscera were securely fastened
together by fine silk threads. The abdomen was closed, and a high
enema of one ounce of brandy and two pints of normal saline solu-
tion was administered before the patient awoke. Throughout the
whole course of his subsequent illness the kidneys acted normally,
and the urinary record may, therefore, be omitted.
Noveynber 15th. 11. 10 a.m., operation. 1.30 p.m., hypodermic
injection of digitalin, gr. i/ioo ; strychniae sulph., gr. 1/40. 2.40
P.M. Patient conscious. Temp., 98.4° F. \ pulse, 90. 4 p.m. Temp.,
98.4°; pulse, 90. Hypodermic injection of digitalin, gr. i/ioo;
strychniae sulph., gr. 1/40. 8 p.m. Nutritive enema, peptonized milk,
§vj ; brandy, .5J. Pulse, 98. Hypodermic injection as before, with
addition of codeiae sulph., gr. 1/4. Temp., 99. 4°. 11 p.m. In pain.
Hypodermic of strychnige sulph., gr, 1/40; digitalin, gr. i/ioo; mor-
phiae sulph., gr. 1/8,
xdth. 2 A.M. Temp., 100.2°; pulse, 116. High enema of one pint
normal saline, six ounces of peptonized milk, and one ounce of
brandy. Hypodermic of strychniae and digitalin as before. 5 a.m.
Hypodermic of strychniae sulph., gr. i/ioo; digitalin, gr. 1/40.
Temp., 101° ; pulse, 100. 8 a.m. Nutritive enema, peptonized milk,
gvj ; brandy, %. Chipped ice in mouth. 9 a.m. Enema passed
from bowels, it a.m. Temp., 101°; pulse, 112. Hypodermic of
strychniae sulph., gr. 1/40; digitalin, gr. i/ioo. 11.30 p.m. Nutritive
enema with ten drops of laudanum. Hypodermic of strychnia^ sulph.,
gr, 1/40; digitalin, gr. i/ioo. Temp., 101°; pulse, 108. 3 p.m.
VICIOUS CIRCLE AFTER G AST RO- ENT EROSTO M Y . 4I9
Passed enema from bowels. 4 p.m. Temp., 101° ; pulse, 104. Chipped
ice. 5.30 P.M. Hypodermic of strychnisesulph., gr. 1/40; digitalin, gr.
i/ioo. 6.40 P.M. Nutritive enema as before. Temp., 100.6°; pulse,
108. 8 P.M. Hypodermic of strychniae sulph., gr. 1/40; digitalin,
gr. i/ioo. II P.M. Hypodermic of strychniae sulph., gr. 1/40; digi-
talin, gr. i/ioo. II P.M. High enema of normal saline, Oj ; pepton-
ized milk, 5iv; brandy, 5J.
i-jth. 1. 15 A.M. Temp., 99.3° ; pulse, 102. Hypodermic of strychniae
sulph., gr. 1/40, digitalin, gr. i/ioo. 4.30 a.m. Passed some of the
enema and urinated ; had rested very well during night. 7 a.m.
Temp., 99.4; pulse, 100. Hypodermic of strychniae sulph., gr. 1/40;
digitalin, gr. i/ioo. Nutritive enema, peptonized milk, gvj ; brandy,
§j. II a.m. Passed some of the enema. Temp., 100.2° ; pulse, 120.
I P.M. Nutritive enema, peptonized milk, gvj ; brandy, ,5J. 1.30
p M. Temp., 100.8°; pulse, 112; 5 P.M. Beef-broth by mouth, 3j.
Temp., 100.2°; pulse, 132. 6.40 p.m. Nutritive enema as before.
7 p.m. Passed portion of enema. 11.30 p.m. Temp., 99°; pulse, 98.
Beef-broth by mouth, 5J.
18/-^. I a.m. Nutritive enema with tr. opii., n\^x. 6 a.m. Beef-
broth, 5J. Temp., 99°; pulse, 92. 7.50 a.m. Beef-broth, §j. 8.3o
A.M. Nutritive enema of peptonized milk, §vj ; brandy, ^j ; tr. opii,
ni^x. 9.20 A.M. Enema passed from bowels. Temp., 98.8°;
pulse, 96. Milk by mouth, gij. 11 a.m. Wound dressed; healing
per primam. i p.m. Nutritive enema as before. 3.30 p.m. Enema
passed from bowels. 4 p.m. Temp., 99.2° ; pulse, 100. Milk by
mouth, 3iij. 5. p.m. Milk by mouth, 3iij. 6 p.m. Milk by mouth,
.^iij. 7 P.M. Milk by mouth, 5iij. 11.40 p.m. Temp., 98.4°; pulse,
92. Nutritive enema. Milk given in small quantities every hour.
\<)fh. Temp., 98.4° ; pulse, 96. Milk given in small quantities every
hour. 8 A.M. Chicken-broth by mouth, |ij. Milk given in small
quantities every hour. 10 a.m. Beef-broth by mouth, 5ij. Milk
given in small quantities every hour. Bowels moved. Nutritive
enema and some fecal matter. 5 p.m. Milk and custard by mouth.
Temp., 99°; pulse, 84. 7.45 p.m. Milk, ,^iv. 9 p.m. Custard, §j.
10.30 p.m. Milk, 3ij. 11.20 P.M. Milk, 5ij.
20th. 2 A.M. Milk, f iij. 7 A.M. Temp., 98.3° ; pulse, 80. 4 p.m.
Temp., 98.4°; pulse, 104. 5 p.m. Milk-toast and gruel. 11 p.m.
Patient now became cold and clammy, and complained of severe
abdominal pain. Heat applied to abdomen and extremities.
2ist. I a.m. Pain continues. Codeiae sulph., gr. j ; spir. frumenti,
420 MC GRAW,
§j; to be given every three hours. Patient continued anxious and
distressed during night. 7 A.M. Temp., 100°; pulse, 120. Milk,
§ij. 9 A.M. Bowels moved by enema. 10 a.m. I saw him for the
first time after his pain began. I found the upper part of the abdo-
men swollen. Patient complained of nausea and pain. Believing the
trouble due to overfeeding and indigestion, I oidered nitromuriatic
acid, pepsin, and brandy, and directed more moderation in feeding.
Temp., 92.4°; pulse, 100. 12 M. Beef-broth, |j. i p.m. Medicine.
Chicken-broth, 3J. 4 P.M. Milk, §iij. 7 p.m. Temp., 99.2°; pulse,
116. Easier. 10.30 p.m. Great pain in abdomen. Suffers from
hiccough. 1 1. 1 5 P.M. Milk, gij.
22d. Patient slept little during the night, and had constant hic-
cough. Food discontinued during night. 7 a.m. Temp., 99.3°;
pulse, 96. 8 A.M. Malted milk, giij. 10.30 a.m. Beef-broth, §ij.
Abdomen still swollen. Patient in considerable distress. 3 p.m.
Malted milk, 5iij. 4 p.m. Temp., 99.4° ; pulse, 112. Gruel, strained,
5ij. Vomited thick, dark yellow fluid, about gvj. All food by
mouth was now discontinued. Patient suffered from abdominal pain
and hiccough. 7 p.m. Temp., 99.2°; pulse, 108. 9 p.m. Nutrient
enema, peptonized milk, gvj ; brandy, 5J ; tr. opii, n\,x. This was
retained. Morph. sulph., gr. 1/8 by hypodermic injection.
23^'. 3 a.m. Nutrient enema as before ; retained, and patient rested
well. 8.30 A.M. Bowels moved by simple enema. 9 a.m. Nutritive
enema, i p.m. Nutritive enema. 3 p.m. Strychnige sulph., gr. 1/40
by hypodermic injection. Temp., 99° ; pulse, 88. 4 p.m. Temp.,
98.6°; pulse, 88. 5 P.M. Urinated and passed enema. 7 p.m.
Nutritive enema. Strychnise sulph., gr. 1/40 by hypodermic injection.
9 P.M. Urinated and passed enema.
24M. I A.M. Nutritive enema. 3.20 a.m. Urinated and passed
enema. During the night the patient rested fairly well. 7 a.m. Temp.,
97.3°; pulse, 80. Nutritive enema. 11 a.m. Evacuation of bowels.
12 a.m. Evacuation of bowels. Clear broth by mouth, 5ij. i p.m.
Nutritive enema. 4 P.M. Temp., 98.3°; pulse, 108. 5 p.m. Strained
gruel, gij. 7 P.M. Nutritive enema. 8.30 p.m. Beef-tea, giv.
25///!. I A.M. Nutritive enema. Patient rested very well during the
night, though troubled with occasional hiccough. 8 a.m. Fecal
movement after simple enema. Sutures removed. Wound healed
by first intention. 12 M. Cup of tea. 2 p.m. Nutritive enema. 5 p.m.
Temp., 98.4°; pulse, 78. 11 p.m. Malted milk. 11.30 p.m. Chicken-
broth.
VICIOUS CIRCLE AFTER G ASTRO-ENTE ROSTO M Y . 42 I
26M. I A.M. Nutritive enema. Rested well all night. 7 a.m. Temp.,
98°; pulse, 88. 8 a.m. Nutritive enema, retained one hour. 12.45
P.M. Strained beef-soup, ^iij. Patient complained of severe abdomi-
nal pain. I P.M. Clear soup, ^iij. 1.40 p.m. Nutritive enema. 2.30
P.M. Bowels distended in upper part, great pain. Hypodermic of
morph. sulph., gr. 1/6; atropine sulph., gr. i/ioo. 4 P.M. Temp.,
99.4°; pulse, 98. Pain lessened. 5.30 p.m. Beef-broth, 5iij. 7 p.m.
Nutritive enema. 9 p.m. Malted milk by mouth, gij. In more pain.
9.45 P.M. Hypodermic of morph. sulph., gr. 1/6; atrop. sulph.,
gr. i/roo.
2'jth. Patient slept well, but complains again of pain. 7 a.m. Temp.,
98.6° ; pulse, 88. Simple enema expelled with much gas. 8 a.m.
Nutritive enema — retained. 9.30 a.m. Egg-nog, 5ij. 11 a.m. Com-
plains of pain. Prescribed morph. sulph., gr. 1/32, in peppermint-
water, every hour until relieved. 12 m. Egg-nog, sj. 2 p.m. Nutritive
enema — retained fifteen minutes. 2.30 p.m. Chicken-broth, ^ij. 7
p.m. Nutritive enema — retained one hour. Temp., 99°; pulse, to8.
8.30 P.M. Vomited about 5iv of brown fluid. Strychnise sulph.,
1/50 by hypodermic injection. 9.15 p.m. Nutritive enema. I now
gave directions for an operation early next morning.
28//^. I a.m. Vomited a quantity of dark colored fluid. Temp.,
97.4°; pulse, 132. Patient slept until 2.45, when he awoke feeling
very faint. Hypodermic of strychniae sulph., gr. 1/50. 3 a.m. Nutri-
tive enema. Intense pain in abdomen. 4.15 a.m. Hypodermic of
strychniae sulph., gr. 1/50. Digitalin, gr. i/ioo. Collapse and death
at 4.45 A.M.
Five hours after death I made a post-mortem examination, which,
for certain reasons, had to be very hurried. I opened the wound and
examined the bowels. I have to regret that I omitted, in my haste,
to note the relative positions of the afferent and efferent limbs of the
jejunum. I found the afferent portion, the duodenum and stomach,
all enormously distended with fluid, and the afferent (wrongly printed
in the N. Y. Medical, Journal as efferent) tense. I had not allowed
sufficient length to that portion of the intestine, and it made a decided
traction upon the stomach. Removing the stomach, with the adherent
jejunum, I found a perfect and beautiful anastomosis with an orifice
five centimetres long.
I will reserve comment on this case until I have reported
Case II.
422 MC GRAW,
Case II. — Mr. P. L., aged fifty-two years, has been ill with dyspeptic
symptoms several years. During this time he had suffered from
eructations of gas, distress at the pit of the stomach, and occasional
vomiting. This had gradually increased in severity until September,
1900, when the vomiting became so frequent as to indicate obstruc-
tion. His physician. Dr. Chapoton, washed the stomach out fre-
quently, with only temporary relief. Analysis of test breakfasts, made
at intervals, showed the presence of hydrochloric acid in large pro-
portion and an entire absence of lactic acid. A small indentation
could be felt to the right of the median line in the hypochondriac
region, which changed its position and seemed movable.
The diagnosis of Dr. Chapoton, in which I concurred, was that of a
benign pyloric tumor. The stomach was only moderately dilated.
He entered St. Mary's Hospital for operation on January 9th, but
was kept under observation for three days, during which every effort
was made by nutritive enemata and frequent hypodermic injections
of strychniae sulph. and digitalin to increase his strength. His
stomach was washed out with boric- acid solutions. His temperature
ranged during these three days from normal to 102.2° F. His highest
point was attained on November nth, at 3 p.m. His temperature on
November 12th, one hour before operating, was 100.2° F. His urine
was normal, and continued to be so during his whole illness. On
November 12th, at 10 a.m., operation after usual preparations.
Incision ten centimetres in length, beginning about three centimetres
above the navel in the median line, and carried transversely to the
left. The stomach was found free of all adhesions and only a very
little enlarged. The pylorus was the seat of a dense tumor about as
large as a walnut. There were no infected glands that I could feel.
I brought the jejunum up in front of the colon and joined it to the
posterior wall of the stomach by an elastic ligature at a distance of
about fifty centimetres from the duodenum. The operation was then
completed, two pints of normal saline solution with one ounce of
brandy injected high up in the colon, and the patient put to bed.
January 12th. 5 p.m., resting quietly. Temp., 100.4° F. 6.15
P.M., hypodermic of strychnige sulph., gr. 1/60; morphine sulph.,
gr. 1/4; digitalin, gr. i/ioo. 10 p.m. Temp., 99.6° F. ; pulse, 96.
Troubled with hiccough. 12 p.m. Hypodermic of strychnia: sulph.,
gr. 1/60 ; digitalin, gr. i/ioo.
13M. 12,30 A.M. Nutritive enema of peptonized milk, 5vj ; brandy,
§j. Urination painful and frequent. 425 a.m. Temp., 99.2°;
VICIOUS CIRCLE AFTER G A ST RO- ENT E ROSTO M Y . 423
pulse, 94. Hypodermic of strychniae sulph., g. 1/60; digitalin, gr.
i/ioo; morph. sulph., gr. 1/6. Patient slept well at intervals, but
complained of sharp abdominal pain. 7 a.m. Nutritive enema —
retained. 8.30 a.m. Temp., 99 2° F. ; pulse, 94. Hypodermic of
strychniae and digitalin as before. 11.30 a.m. gxiv urine by catheter,
urotropin, grs. v; salol, grs. xx, to be given every six hours in
nutritive enema. Temp., 99.2° F. ; pulse, 94. 12.30 p.m. Nutritive
enema — retained. Strychnise sulph., gr. 1/60; digitalin, gr. i/ioo.
I P.M. Hypodermically. 5.40 p.m. Passed urine with great pain.
Temp., 100 1/5° F. ; pulse, 96. Strychnise sulph., gr. 1/60; digitalin,
gr. i/ioo, hypodermically. 7.35 p.m. Temp., 101.2°; pulse, 118.
Urinated, ^ij. Had a chill lasting fifteen minutes. Bowels moved.
7.45 p.m. Morph. sulph, gr. 1/4, hypodermically. 8 p.m. Urinated;
passed gas from rectum. 8.50 p.m. Very restless ; pulse, 124; passed
Sij urine, 9 p.m. Temp., 103.4° F.; pulse, 128. Urinated again;
very restless, but sleeps a few minutes at a time. Bowels moved ;
offensive odor. 10.30 p.m. Temp., 104.2° F.; pulse, 130, very
weak. Hypodermic of strychnine sulph., gr. 1/40; digitalin, gr. i/ioo.
Foot of bed elevated and normal saline Oj, spir. frumenti, §j, injected
under skin of both axillae.
i^th. 12.30 A.M. Nutritive enema given, but soon expelled. Hypo-
dermic of strychniae, gr. 1/40; digitalin, gr. i/ioo. 1.30 a.m. Temp.,
101.4° F.; pulse, 120. Stool of black and offensive liquid. Urin-
ated. Sleeps at intervals. 3 a.m. gij cold water by mouth. 4.15
A.M. Temp., 100.2° F. ; pulse, 114. Hypodermic of strychniae
sulph., gr. 1/40; digitalin, gr. i/ioo; 5iv cold water by mouth.
6.10 A.M. Cold water, siv ; has rested quietly. 7.30 a.m. Temp.,
99.2° F.; pulse, 102. Hypodermic of strychniae sulph., gr. 1/40;
digitalin, gr. i/ioo. 8.30 a.m. Nutritive enema of peptonized milk,
§vj ; brandy, .5J, tr. opii. gtt. xx, retained. 10 a.m. Wound
dressed. Healing per primam. 10.40 a.m. Temp., 98.4°; pulse, 98.
Glass of water by mouth. 11. 15 a.m. Glass of water. 12.30 p.m.
Temp., 99°; pulse, 100. Hypodermic of strychniae and digitalin.
1.30 P.M. Beef-broth, §j, by mouth. 2.15 p.m. Nutritive enema.
Urinated. 3.15 p.m. 5] of hot tea. 3.30 p.m. Strychniae sulph.,
gr. 1/60; digitalin, gr. i/ioo, by hypodermic. Urinated. 5.20 p.m.
Passed urine, gxi. Temp., 99°; pulse, 98. 6.15 p.m. Chicken
broth 5J. Urinated. Hypodermic of strychniae sulph., gr. 1/60;
digitalin, gr. i/ioo. 7 P.M. Nutritive enema, retained. Urinated;
resting quietly. 9 P.M. Temp., 99° ; pulse, 94. Hot tea, 5J. Patient
424 MC GRAW,
complains of pain in abdomen. 11.15P.M. Hypodermic of strychniae
sulph., gr. 1/60; digitalin, gr. 1/60; morph. sulph., gr. 1/8. 12 p.m.
Temp., 98.4°; pulse, 90.
15M. I A.M. Nutritive enema, retained. 1.40 a.m. 5J, chicken
broth. 5.30 A.M. Hypodermic of strychnise sulph., gr. 1/40; digi-
talin, gr. i/ioo. Complains of great abdominal pain. 8.30 a.m.
Temp,, 98.2°; pulse, 102. Liquid peptonoids, giij by mouth.
Bowels moved freely by aid of simple enema. Urinated. 9.30 a.m.
Hypodermic of strychnise and digitalin. 9.45 a.m. Patient vomited
greenish fluid. 11. 15 a.m. Nutritive enema. 11.30 a.m. Slight move-
ment of bowels. Upper part of bowels swollen. Patient nauseated.
12.15 P-^^' Temp., 98.4°; pulse, no. Sleeping. 4 P.M. Hypo-
dermic strychniae sulph., gr. 1/60; digitalin, gr. i/ioo. 5 p.m.
Temp., 99.3° F. ; pulse, 112. 5.30 p.m. Slight movement of bowels,
and again at 6.15. 6.20 p.m. Nutritive enema of peptonized milk,
5vj ; brandy, 5]. 8 p.m. Hypodermic strychnise sulph., gr. 1/60;
digitalin, i/ioo. Bowels moved slightly. Urinated. Cold water
giv. Complains of abdominal pain. Bowels distended above navel.
II. 15 p.m. Morph. sulph., gr. 1/4 by hypodermic injection. 12 p.m.
Patient vomited dark green fluid. Cold water 5iv.
i6f/i. 12.10 a.m. Hypodermic of strychnine sulph., gr. 1/60; digi-
talin, gr. i/ioo; temp., 98.8° F.; pulse, 106. Complains of pain.
6.45 A.M. Urinated. Cold water, 5iij. Patient had slept fairly well
during night. 7.20 a.m. Temp., 98.2°; pulse, 96. Nutritive enema.
Hypodermic of strychnise sulph., gr. 1/60; digitalin, gr. i/ioo. 8.45
a.m. Vomited dark green fluid. 10.50 a.m. Vomited dark green
fluid. 11.20 a.m. Cold water, ^ij. 12 m. Cold water, gij. Taken
to operating-room.
The wound, which was healing by first intention, was reopened, and
from its inner end an additional incision was carried directly down-
ward for a distance of eight centimetres. This made a triangular
flap, which, when reflected, exposed the stomach and all of the intes-
tines, which lay in the upper half of the abdominal cavity to the left
of the median line. I found revealed a curious condition of things.
When operating I had, as usual, on joining the intestine to the
stomach, turned the intestine around so as to make its course run
from left to right. The afferent portion was then on the left side of
the body, the eff'erent, lying over it on the right side. I now found
the position reversed. The eff'erent limb was on the left and the
afferent limb on the right. To accomplish this change the stomach
VICIOUS CIRCLE AFTER G ASTRO- ENT E ROSTO M Y . 425
had been partly twisted on its axis. The stomach was contracted and
contained very Jiitle fluid. The efferent limb of the jejunum was
contracted and empty. The duodenum and adjacent portion of the
jejunum, which by the way was fully fifty centimetres in length, were
enormously distended. I do not, indeed, remember to have ever met
with the small intestine so greatly enlarged. I made a small incision
and evacuated a large quantity of green fluid in which bile was
evidently mixed with the food he had taken.
The afferent and efferent limbs of the jejunum were now joined by
means of a Murphy button about fifteen centimetres from the stomach,
and the abdomen closed.
16th. 1.20 P.M. Patient conscious. Hypodermic of strychniaesulph.,
gr. 1/60; digitalin, gr. i/ioo. 2.30 p.m. Temp., 100° F. ; pulse, 108;
resting quietly. 3.15 p.m. Involuntary stool. Eructation of gas. 4.20
P.M. Temp., 102.2° F. ; pulse, 126. Urinated involuntarily. Com-
plains of pain in abdomen. Eructations of gas. 5.30 p.m. Hypo-
dermic strychnine sulph., gr. 1/60; digitalin, gr. i/ioo; temp.,
101.4° F.; pulse, 116. 6.30 p.m. Temp., 100.6° F. ; pulse, 116.
Nutritive enemata. Cold water, giv, by mouth. 8.30 p.m. Temp.,
100.2° F.; pulse, 116. Hypodermic, strychnise sulph., gr. 1/60. Cold
water, .^iv, by mouth. Digitalin, gr. i/ioo. 9.30 p.m. Temp.,
100.2° F, ; pulse, 114. Cold water, giij. Eructations of gas. Vom-
ited green fluid. Complains of abdominal pain. 11 p.m. Urinated
voluntarily, gvj. Cold water, giv, by mouth. 11.30 p.m. Strychnise
sulph., gr. 1/60; digitalin, gr. i/ioo, by hypodermic injection.
Patient fell asleep.
I'jth. 12.30 a.m. Temp., 100.2° F.; pulse, 108. Cold water, gij ;
nutritive enemata, retained, i a.m. Restless. 5iij cold water. 2.30
a.m. Hypodermic of strychnise sulph., gr. 1/60 j digitalin, gr. i/ioo.
4.45 a.m. Has rested well and slept since 2.30. Temp., 99.2°;
pulse, 100. Cold water, ^ij. Complains of abdominal pain. 5.30
A.M. Hypodermic of strychnise sulph., gr. 1/60; digitalin, gr. i/ioo.
Urinated. 8.30 a.m. Temp., 99.4°; pulse, 100. Slept two hours.
Cold water, giij. Nutritive enema, retained. 9 a.m. Vomited dark
green fluid. Resting quietly. 10 a.m. Vomited gij dark green fluid.
10.35 A.M. Temp., 90.2°; pulse, 106. 12.30 p.m. Hypodermic of
strychnise sulph., gr. 1/60; digitalin, gr. i.ioo. Cold water, sij.
I P.M. Nutritive enema. Patient slept an hour. 3.15 p.m. Urinated.
Cold water, 5ij. 4 P.M. Temp., 90.4°; pulse, 102. Hypodermic
strychnise sulph, gr. 1/60; digitalin, gr. i/ioo. Cold water, giij.
426 MC GRAW,
6.15 P.M. Eructation of gas. Urinated. Bowels washed out with
simple enema. 7 p.m. Temp., 99.2° ; pulse, 98. Nutritive enema
retained. Cold water, giv. Resting quietly. 8.30 p.m. Strychnise
sulph., gr. 1/60; digitalin, gr. i/ioo, by hypodermic. 8.55 p.m. Glass
of water. Eructation of gas. 11 p.m. Has slept two hours. Much pain
in abdomen. Eructations of gas. 12 p.m. Temp., 99°; pulse, 100.
18//^. 12.30 A. M. Hypodermic of strychniae sulph., gr. 1/60 ; digi-
talin, gr. i/ioo; morph. sulph., gr. 1/4. i a.m. Nutritive enema.
Patient slept two hours. Awoke with hiccough. 4.30 a. M. Temp.,
99°; pulse, 100; hypodermic of strychnise sulph., gr. 1/60; digitalin,
gr. i/ioo. Glass of water. 7 a.m. Has slept two hours. Temp.,
98.8°; pulse, 94. Glass of water, 3iij. Malted milk. 8.10 a.m.
Nutritive enema, retained. Hypodermic of strychnise and digitalin.
10 A.M. Eructation of gas. giv malted milk. Hiccoughs. 11 a.m.
Temp, 99°; pulse, 90. 5J malted milk. 1.25 p.m. Nutritive enema,
retained. 5J malted milk. Glass of water. Troubled much with
hiccough. 2.30 P.M. Urinated. Stool, gj malted milk. 3 p.m.
Malted milk sj. Slept one hour. 5 p.m. Temp., 100.2° F.; pulse,
96. Malted milk §j. Hiccoughs troublesome. 8 p.m. Hypodermic,
strychnia and digitalin. Malted milk, ^j. 9 p.m. Temp., 100.2°;
pulse, 88. Nutritive enema. 11.30 p.m. gj malted milk. Hiccoughs.
igth. 1.45 a.m. Unable to sleep by reason of hiccough. Hypo-
dermic of morph. sulph., gr. 1/6. 3.30 a.m. Slept since 1.45 a.m.
Hypodermic of strychnise and digitalin. 6 a.m. Nutritive enema.
Has taken much water during night. Suffers still from hiccough.
9.35 A.M. Hiccough continues. Wound dressed. Slight superficial
suppuration. Acid hydrocyan. dilut., 3J ; aq, menth. piperit., 5iij,
a teaspoonful every hour until relieved. 1.30 a.m. Cup of tea. Hic-
cough still continues. 12.45 ^•^^- Hypodermic, strychnise and digi-
talin. Hot tea, gij. 1.45 p.m. Nutritive enema. Hiccoughs at
intervals. 2.30 p.m. Vomited greenish fluid. 3.30 p.m. Vomited
greenish fluid. Hiccough continues. 6.30 p.m. gij hot tea. 7 p.m.
Temp., 100.6°; pulse, 100. Has rested well since 4 o'clock. 7.30
P.M. Hiccough, but not so bad. 9 p.m. Nutritive enema. Hypo-
dermic of strychnise sulph., gr. 1/60; digitalin, gr. i/ioo; morph.
sulph., gr. 1/8.
20th. 12.30 a.m. Temp., 100.2°; pulse, 106. Hypodermic of
strychnise and digitalin. Hot tea, p;ij. Complains of abdominal
pain. Abdomen soft ; not tender or distended. 4.45 a.m. Nutritive
enema. Hot tea, 5ij. 8 a.m. Slept well. No hiccoughs. Stool
VICIOUS CIRCLE AFTER CAST RO- ENTEROSTOMY. 427
after simple enema. 10 a.m. Hot tea, 5!] Wound dressed. 11 a.m.
Egg-nog, 5ij. 11.35 ^•^^- Egg-nog, gij. 12.10 p.m. Strained soup,
gij. 2 P.M. Nutritive enema. 2.10 p.m. §ij egg-nog. 3 p.m. ^ij
egg-nog. Free movement of bowels. 3.30 p.m. Temp., 101.2° F.;
pulse, 106. §ij milk and lime water. Eructations of gas. 6.30 p.m.
3J, milk and lime water. 8.45 p.m. Temp., 100.4°; pulse, 106.
Vomited green fluid. 9 p.m. 3J milk and lime water. Urinated.
9 20 P.M. Nutritive enema. Hypodermic of strychnige and digitalin.
9.30 P.M. Vomited green fluid mixed with milk. 11.30 p.m. Patient
restless and in pain. Morph. sulph., gr. 1/4.
2IJ-/. Morph. sulph., gr. 1/8, hypodermic. 2.15 a.m. Hot tea, §j.
6 A.M. Free movement of bowels. Temp., 100.2°; pulse, 104.
Hot tea, 5j. 7 A.M. Temp., 100.2°; pulse, 108. Had slept at
intervals, but had complained of much pain. Hypodermic injection
ofstrychniae and digitalin. Hot tea, §j. 9 A.M. Has slept since 7
o'clock. 9 A.M. Wound dressed. 11-35 ^•^^- Temp., 100.4°;
pulse, 98. Slept since 9 a.m. Brandy and water, §j. Patient feels
weak. 12 A.M. Brandy and water, 3J. Urinated. 12.45 p.m. Brandy
and water, 3J. 1.20 p.m. Temp., 101.2°; pulse, 112. Nutritive
enema. Hypodermic of strychnise sulph., gr. 1/60; digitalin, gr.
t/ioo. Egg-nog, sij. 2.30 p.m. Brandy, giv. 3 p.m. Egg-nog,
3j. 4.10 P.M. Egg-nog, 5ij- 4-3° P-M. Temp., 101.6°; pulse,
104. Hypodermic of strychnine and digitalin. 5 p.m. gij mutton
broth. 5.30 P.M. Brandy, ^iv. 6.30 p.m. giij albumin. 7 p.m.
giv brandy. 7.45 p.m. gij egg-nog. 8.30 p.m. 3iij white of egg.
9 P.M. Temp., 101.6°; pulse, 104. Brandy, |j. Nutritive enema
retained. 11 p.m. Egg-nog, gij. Urinated.
22^. 2.30 A.M. Complains of pain in abdomen. White of egg, 3ij.
Hypodermic of strychniae and digitalin with one-sixth gram of
morphia sulph. 4.45 a.m. Slight evacuation of bowels. 5.15 a.m.
Nutritive enema. Brandy, jij. Slept well during night. 7.45 a.m.
Temp., 99.4° F.; pulse, 94. Brandy, ^ij. 9 a.m. Bowels moved
by simple enema. Egg-nog, ^ij. Wound dressed and sutures re-
moved. 10 A.M. Brandy, gij. 10.35 a.m. Strained gruel, gij. 11
A.M. Egg-nog, siij. 12.35 p.m. ^iv white of egg. i p.m. Mutton
broth, sij. 1.30 p.m. Egg-nog, 3iij. 1.45 p.m. Nutritive enema.
2.20 p.m. Brandy and water, gij. 3 p.m. Cup of tea. 3.30 p.m.
Brandy, ^ij. 4.40 p.m. Slept 3/4 hour. Strained gruel, 3ij. 6 p.m.
Egg-nog, 3ij, and at 6.35 brandy, gij. 7 p.m. Temp., 100.6°;
pulse, I02. 8.15 P.M. Brandy, gij. 8.45 p.m. Beer, ^iv. 9 p.m.
428 MC GRAW,
Nutritive enema. Hypodermic strychniae sulph., gr. 1/60 ; digitalin,
gr. i/ioo. 10 P.M. Urinated and bowels moved freely. 10.15 ^•^'
Beer, 3iv. 11.40 p.m. Temp., 102.6°: pulse, 120. Egg-nog, gij.
Patient very weak.
23^/. 1. 15 A.M. Temp., 103.2° ; pulse, 124. Hypodermic strychnige
sulph., gr. 1/40; digitalin, gr. i/ioo; brandy, ^ij. 4 A.M. Temp.,
102°; pulse, 118. Nutritive enema. 5 a.m. Hypodermic injection
strychniae sulph., gr. 1/60; digitalin, gr. i/ioo. Slept at intervals,
but very restless and weak. 7 a.m. Temp., 101.4°; pulse, 108.
Urinated. Evacuation of bowels. Mutton broth, .^ij. 8.30 a.m.
Hypodermic of strychniae sulph., gr. 1/60; digitalin, gr. i/ioo.
10.20 A.M. Temp., 100.2° ; pulse, 106. Cup of tea. 11 a.m. Chicken
broth, siv. Resting quietly. 12.10 p.m. Egg-nog, ^iij. Very
hungry. 1.15 p.m. Beefsteak, 3J, cut fine, and tea. 2 p.m. Temp.,
100.4°; pulse, 114. 2.45 P.M. Egg-nog, giij. 3.10 p.m. Brandy
and water, 3ij. 4 p.m. Temp., 100.4°; pulse, no. 5 p.m. Cup of
tea. 5.45 P.M. Brandy and water, gij. 9 p.m. Egg-nog, giij. 9.30
P.M. Temp., 100.4°; pulse, no. 11.45 ^•^^- Has slept two hours.
Brandy and water, ^ij.
24/A. 2.30 A.M. Temp., 101.4°; pulse, 112. Cup of tea. 5 a.m.
Egg-nog. 8.30 a.m. Temp., 99.2°; pulse, 94. Had rested well and
slept since two o'clock. 10.30 a.m. Egg-nog. Dressing removed and
remainder of stitches removed. Temp., 99.6°; pulse, 96. 11-15
a.m. Small piece of beefsteak with toast and coffee. 12.15 P-^^-
Brandy and water. 4.45 p.m. Urinated and had stool, dark in color
and constipated. 5 p.m. Oatmeal porridge. Egg, toast, and tea.
6.15 P.M. Temp., 100.2°; pulse, 102. 8.30 p.m. Egg-nog. 9.30
p.m. Cup of tea.
25//^. 4 A.M. Beefsteak, milk-toast, coffee. Patient had slept well
all night. Temp., 99.4°; pulse, 100. 9 A.M. Oatmeal porridge,
egg, toast, and coffee, n a.m. Egg-nog. 12.30 p.m. Soup, chicken,
bread, tea, and pudding. 5.30 p.m. Beefsteak, milk-toast, tea.
I will omit the detailed account of his convalescence and will give
in short the remainder of the history. From now on he was allowed
to eat according to his desire. His temperature fell to normal and he
continued in comfort until February 4th. On January 29th he was
allowed to sit up for the first time. On January 31st he began to
walk. He had no complaints to make except of numerous places on
the thighs which had been the seat of small abscesses as the result of
hypodermic injections. On February 4th he passed the button. At
VICIOUS CIRCLE AFTER G A ST RO- ENTEROSTOMY. 429
four o'clock on that day he had a chill with fever; temp., 101°;
pulse, no. At 8 P.M. Temp., 103.6°; pulse, 158. A second
heavy chill. 8.30 p.m. Temp., 104,4°; pulse, 148. 9 p.m. Vom-
ited his dinner. His temperature then fell to normal and remained
so until February 9th, when, without apparent cause, he had a chill
with a temperature of 102.2° F. The cause of these chills was
obscure. He left the hospital on February 12th, feeling well.
On March ist he walked into my office, apparently well, and com-
plaining only of weakness. He had had no more fever and showed
no evidences of indigestion or obstruction. If we examine these two
cases critically we will find marked differences in the symptoms and
course of their trouble. In order to make the contrast plainer I will
summarize the two records.
Case I. began on the evening of November 17th — fifty-three
hours after the completion of the operation — to take nourish-
ment by the mouth. During the three days ending November
20th, 5 P.M., he had taken fluids by the mouth aggregating
approximately three pints in bulk. At 1 1 p.m., November
20th, he was seized with severe abdominal pain, the upper part
of the abdomen was found swollen, and he became clammy and
cold. He had been so comfortable during the three days of
mouth-feeding that I did not think, as yet, of serious trouble,
and did not stop giving nutriment by mouth until November
22d, when, for the first time, he vomited a quantity of green,
bitter fluid. He began again at noon, November 23d, to take
small quantities of food by mouth, and, except for an occasional
hiccough, was comparatively comfortable until noon of Novem-
ber 26th, when he began again to complain of abdominal pain
and distention and troublesome hiccough. His pulse on the
morning of November 27th was 88, and of good volume; his
temperature, 98.3°. At 8.30 P.M., and again on November
28, at I A.M., he vomited, and then collapsed and died.
Case II., operated on January 12th, began to take water by
mouth at 3 a.m. January 14th, and at 1.30 p.m., of the same day,
small quantities of nourishing liquids. He had taken, in all,
less than a pint of liquids — chiefly water — when on January
15th, at 9.45 A.M., he vomited a green, bitter fluid. He had
430 MC GRAW,
complained previously of abdominal pain and distention. He
vomited again at midnight, and on January i6th at 8.45 A.M.
and 10.50 A.M. At 12 o'clock he was operated on for the second
time.
In Case I. the post-mortem revealed an empty condition of
the efferent jejunum and an enormously distended stomach,
afferent jejunum and duodenum. The afferent jejunum was tense
and evidently too short to allow free motion. I must regret that
it did not occur to me before handling the intestines to note
their position in siUi.
In Case II. the abdominal section showed the duodenum and
adjacent jejunum vastly distended; indeed, I do not think that
I have ever seen a larger small intestine. The stomach was
small, nearly empty, and peculiarly twisted, as I have described.
In the first case the patient vomited only once until the night
of the final collapse, when he vomited twice. He did not show
any signs of distress at all until after three days of mouth-feed-
ing, whereas the second patient began almost immediately to
complain of pain, and in less than thirty-one hours after his first
mouthful of water vomited bile. This bilious vomit may be
regarded as the first symptom of a completed anastomosis, and
is of importance, as it is the first index obtained of the length of
time required for the elastic ligature to accomplish its work in
the human subject. It occurred seventy hours after the com-
pletion of the operation. How long before the vomiting the
anastomosis had been completed is, of course, uncertain.
The absence of vomiting in the first case deceived me in diag-
nosis, as it did not seem possible that so dangerous a condition
could exist without more irritability of the stomach.
It is only recently that I found the explanation of this in a
remarkable article in the Archives fur klinische Chirurgie, by
Dr. George Kelling, of Dresden. I will digress here a moment
to express my admiration for the scientific accuracy of a work
which has been to me a great source of information. I do not
think that anyone who seeks to become an expert in gastro-
enterostomy can afford to neglect its perusal. The articles of
Dr. Kelling are published in the first two numbers of the sixty-
VICIOUS CIRCLE AFTER G AST RO- ENTE ROSTO M Y . 43 1
second volume of the Archives, year 1900. According to Kell-
ing, Hirsch, in 1892, and V. Mering, in 1897, had announced
that the filling of the duodenum inhibited the contractions of the
stomach. During the process of digestion the food passes out
of the stomach in an interrupted series. As soon as the duo-
denum becomes filled, the gastric contractions cease until it
becomes empty, when they again force the ingesta onward.
Kelling confirmed the observations and experimented with ref-
erence to their bearing on the question of gastro-enterostomy.
He found that when the jejunum in a dog was cut in two near
the duodenum, its upper end sewed up, and its lower end joined
to the stomach by an anastomosis, the dog would die, however
well fed. The food passing into the duodenum through the
pylorus would fill and distend the duodenum, which, in this way,
had become a blind pouch, and the inhibitory action of the dis-
tended duodenum would prevent the stomach from discharging
its contents into the open end of the jejunum, and the dog would
die of starvation. I shall not take time and space to relate all
the varied experiments which served to confirm Kelling in his
views ; it is enough to say that it seems proven that the disten-
tion of the duodenum will exert a reflex inhibitory influence on
the stomach which may prevent the success of gastro-enteros-
tomy. That this inhibitory action may not be sufficiently strong
to produce this result in all cases is proven by my second case,
in which there was frequent vomiting, and nearly total evacua-
tion of the contents of the stomach, even though the duodenum
was distended to its utmost capacity. It is possible that the
vomiting in this case may have been produced solely by the
action of the diaphragm and abdominal muscles. It was, how-
ever, without question, this duodenal reflex which enabled my
first patient to live for days with a distended and irritated stomach
without vomiting. It is curious that when the irritation becomes
stronger than the inhibition, and the stomach does contract, it is
with a reversed peristalsis that causes vomiting, but does not pro-
pel the ingesta into the open channel of the attached jejunum.
This happened to Kelling's dogs. They vomited bile, but died
of inanition, although the way was open for the passage of food
432 MC GRAW,
into the small intestine. The importance of these observations
on all questions connected with operations on the stomach can-
not be over-estimated. It is a si7ie qua Jton for the success of a
gastro-enterostomy that the stomach should be able to exert a
normal contractility. Kelling has demonstrated its necessity.
The hydrostatic conditions of the stomach are such that gravity
plays no part whatever in the propulsion of food through an
aperture into the intestine. The stomach floats on the intestines
as on a cushion ; it and its contents and the underlying intes-
tines have nearly the same specific gravity, a fact which, in this
connection, is not altered by the gas which makes certain coils
lighter than others.
If we suppose the stomach after a gastro-enterostomy filled
with food, the gas existing in it and in the connecting coil of the
jejunum would rise to the top or become mingled with the con-
tained fluids. There could be no force, then, to push these fluids
from the stomach into the intestine, except the muscular con-
traction of the stomach itself, for gravity could play no part,
when all parts concerned are of equal gravity. The muscular
contractions of the diaphragm and abdominal wall act alike on
all of the contents of the abdomen, and, therefore, have no influ-
ence in the propulsion of food. Whether, then, the contents of
the stomach would be forced into the intestine or the contents
of the intestine into the stomach would depend upon the relative
power exerted by the two viscera.
If the intestine contracted the more vigorously, the most per-
fect anastomosis could be of no avail, and the only relief which
the stomach could attain must be by vomiting. It is not neces-
sary for the contractile power to be entirely overcome to make
a failure of a gastro-enterostomy. It needs only to be weakened
to a degree that makes it less than that of the intestine into
which it must empty. It is not enough, therefore, to secure a
good exit for ingesta into the efferent limb of the jejunum, for
it is equally important to prevent the collection of fluids in the
afferent portion. In no other way can we secure to the stomach
the ability to exercise its full contractile power, and, in the light
of our present knowledge, the avoidance of " vicious circles"
VICIOUS CIRCLE AFTER G ASTRO- ENTE ROSTO M Y. 433
would seem to depend upon the solution of this problem. At
present I can see no other choice than to combine with every
gastro-enterostomy an entero-enterostomy between the two
limbs of the jejunum. The duodenum could then discharge its
contents into the efferent limb of the jejunum, and the inhibition
exercised on the stomach by its distention be relieved.
The relative positions of the afferent and efferent portions of
the jejunum, as discovered in the second operation on Case II.,
are deserving of special study. At the second operation I had, as
is customary, turned the coil of intestine so as to bring the direc-
tion of its peristaltic movement to correspond with that of the
stomach. At the close of the operation the afferent branch was
on the left and the efferent on the right. On opening the abdo-
men again I found the position reversed. The afferent limb lay
to the right of the efferent, and both were parallel to the long
axis of the body. To accomplish this, the posterior wall of the
stomach had been given a peculiar twist and been bent upon
itself. Whether this was the cause of the ''vicious circle" or
was the effect of vomiting or other disturbance cannot be decided.
It might possibly have been the result of the weight of the long
afferent limb, when filled with fluid, causing it to sink among
the lighter coils containing gas. I cannot avoid the suspicion
that this twist was the cause of all the trouble, and the question
arises in my mind whether the same condition did not occur in
the first case, in which the unfortunate shortness, and conse-
quent tension, of the afferent limb would be an efficient cause of
disturbance. It is evident that such a twist, however produced,
could not take place without obstructing the course of one or
the other intestinal channels.
It is a serious question whether the " vicious circle " may not
actually be caused, in some instances, by the very manoeuvre
which was meant to prevent it. I am not aware that any
numerous observations are recorded of the positions ultimately
assumed by the two limbs of the jejunum months after the opera-
tion. It would be of great interest to know if the loop formed
by turning the intestine during the operation persisted as a loop,
or whether it disappeared in time as the afferent branch ranged
Am Surg 28
434 ^^ GRAW,
itself in its more natural position on the right of its neighbor.
This is certain, that in a few cases these loops have acted as traps
in which the intestine has become entangled. In the sixty-
second volume of the Ai'chives fur klinische Cliiriirgie^ Peter-
sen records three cases in which this accident occurred in
the Heidelberg Clinic alone. How often it may have occurred
elsewhere is not recorded. This practice of turning the intes-
tine to make its peristaltic direction correspond to that of the
stomach originated with Lucke and Rockewitz, in 1887, and
was published in that same unlucky article in which they advised
the profession to unite the stomach with the highest available
coil of small intestine, without taking the time and trouble to
trace out its position, an advice which cost many lives.
The suggestion as to peristaltic direction was adopted with
enthusiasm by the Germans, and accepted by all surgeons as an
article of faith. It may be well to ask whether this dogma has
any assured basis. Is there any practical utility in making the
movement of the ingesta pass in a straight line through stomach
and intestine? If so, is it possible, under the abnormal condi-
tions which exist with an obstructed pylorus, to secure with
certainty any correspondence between the movements of the
stomach and those of the intestine? It must be remembered
that the turning of the intestine adds materially to the difficul-
ties of the operation and to its subsequent dangers. Indeed,
Petersen advises, in order to avoid the dangers of intestinal
entanglement, such as occurred in the three cases recorded from
the Heidelberg Clinic, that the surgeon make an incision large
enough to view the whole field of operation, and that he make
the afferent limb of the jejunum as short as possible. The first
of these directions would lengthen the operation considerably,
and, in the exhausted patients upon whom we have to operate,
materially add to its danger; the second, if closely followed,
would lead to such disaster as I experienced in my first case,
where the afferent jejunum was made too short and caused, I
think, the death of my patient. It is curious that it does not
seem to have occurred to the surgeons who have met with dis-
aster from this practice of turning the intestine that the practice
VICIOUS CIRCLE AFTER G A ST R O- E N T E R O ST O M Y . 435
itself is useless and vicious, and ought to be abandoned. When
there is pyloric stenosis the contraction of the stomach, unable
to cause an outward movement of the ingesta, can only add to
the tension of the gastric walls and thus produce a pressure equal
in all directions. The force will then, inevitably, expend itself
in the direction of the least resistance, and the food will be
ejected through any open channel, regardless of the situation of
its orifice or course of the current. When once in the intestine
it will be shoved along by the muscular contractions of that
viscus after the normal manner. If the way is open into one por-
tion of the intestine, and closed into the other, it must pass into
the open door. If there is a bar across one passage and not
across the other, that bar will control the event. How absurd,
therefore, it is to complicate the operation by an attempt to pro-
duce a movement in a given direction, when the direction of the
movement has no material influence on the issue. The causes
of the " vicious circles " are conditions, either mechanical or
physiological, which prevent the ingesta from following the
desired course into the efferent portion of the jejunum. The
physiological conditions are such as affect the motility of the
stomach. Thus extreme tenuity of the stomach walls, with great
loss of muscular power, would contraindicate a gastro-enteros-
tomy, as there would not be force enough to overcome the
resistance offered by the intestine to the entrance of food. So,
too, the inhibition of gastric movement by a full duodenum may
operate to produce the dreaded vicious circle. As regards the
mechanical obstacles to success, it would not be possible to pro-
vide against all of the flexions and entanglements which might
occur after abdominal operations, but one general rule may
lessen the chances of their occurrence, namely, the rule of
avoiding, as far as possible, all complicated methods which leave
the intestines in unusual and strained positions.
Kelling advises that a small opening be made, as a large one
is more conducive to the formation of a spur. While he is
undoubtedly right in his theory as to the greater liability of the
large aperture to spur formation, I cannot agree with him that
the remedy lies in making a smaller opening of communication.
436 MC GRAW,
Small openings are liable to contractions and closure. In a
recent case of Dr. S. J. Mixter's, of Boston, this contraction had
reduced an aperture which had been occupied by a large Murphy-
button at the time of operation to a hole which would not admit
a lead-pencil. The operation had been performed for the relief
of a gastric ulcer, and as the contraction took place the old symp-
toms recurred and a new operation — this time by an elastic
ligature — was made necessary for its relief These cases are not
infrequent, and would attract more attention if it were not that
the majority of these operations are made for cancerous troubles,
which carry off the patients before the fistulae have so nearly
closed as to cause distress.
Even in cancer, where the life is prolonged for more than a
year, a large aperture can, alone, prevent the recurrence of symp-
toms of obstruction, while in cases of benign stenosis the for-
mation of an orifice so small as to endanger the permanent result
of the operation would be a grave error. The one method of
operating by which the dangers of spur formation may be
avoided, and yet a large orifice made, is that of combining an
enterostomy with a gastro-enterostomy. This method, as is
well known, has been advocated by many surgeons, and if it has
not found universal acceptance, it is because surgeons have feared
to prolong the operations on patients so exhausted as those
which we have to deal with in this line of work. If, in this
double operation, we use Murphy buttons we have two large
foreign bodies which have to find their way through the intes-
tines. If, on the other hand, we use sutures, the operation is very
much prolonged. In either case we double the danger of sepsis
by making two anastomoses by means of open intestinal wounds.
It is here that I wish to urge upon the profession a careful com-
parison of these open-wound methods with that of the elastic
ligature which I introduced in 1891. Whether we use the Mur-
phy button or the suture, we must open the viscera and expose
the patient to a certain danger of sepsis. The elastic ligature
passed through the walls of the intestines permits of no escape
of fluids or gases and reduces that danger to nothing. In
rapidity of performance the elastic ligature is far beyond all
VICIOUS CIRCLE AFTER G AST RO-ENTE ROSTO M Y. 437
other methods. It can be done as quickly as one can pass a
needle and tie a knot. Unlike the suture, it can leave no
unguarded point for the escape of intestinal contents, and it
holds the viscera firmly together until it cuts through the
opposing tissues. It is not like the Murphy button, a compli-
cated mechanism, liable to fail us at a critical moment. It leaves
no foreign body behind which has to be forced through the
intestine and which often passes into the wrong channel. It cuts
its way through the tissues with absolute precision, if properly
applied, and at a period, certainly less than seventy hours, prob-
ably less than fifty, makes a perfectly clean anastomosis with
even edges and a minimum of scar. It has the enormous advan-
tage of enabling the surgeon, without loss of time, to make the
orifice of communication of any desirable length. After a large
experience with this method on dogs, and a small one, li^nited
as yet to six cases, on men, I can see no valid argument that
can be alleged against its use except the time which must elapse
before the patient can be allowed to take food by the mouth.
The question here arises whether in operations by other methods
patients are much better off in this respect. The vast majority of
them suffer for twenty-four hours, or more, with a nausea which
forbids the taking of any food whatever into the stomach for a
varying period after abdominal operations. The motility of the
viscera is impaired, and it is often two or three days, even after
operations which take a perfectly aseptic course, before a rattling
in the bowels and the passage of gas denote the recovery by
the intestines of their power of motion.
It is. of course, useless to put food of any kind into the
stomach when it is not in condition to force it through into
the jejunum, for the stomach itself will not even absorb water.
But not only is the motility of the viscera temporarily sus-
pended by surgical operations, but their power of absorption
also is impaired, and if medicines are given by mouth shortly
after the operation they may not manifest their effects for many
hours after their exhibition. It is reasonable to suppose that the
stomach and jejunum which have been directly injured by a
surgical procedure will suffer more from these impairments of
438 MC GRAW,
function than the large intestine, which is only indirectly affected,
and it is a question whether the patient, after a gastro-enteros-
tomy by any method whatever, will not for the first forty-eight
hours get more nourishment from nutritive enemata than from
mouth-feeding. We may assume that these conditions would
vary widely in different individuals. I am not aware of any
experiments or observations bearing upon the effect of intesti-
nal operations on the motility and power of absorption of the
various viscera, and it is impossible to make absolute statements
regarding them until we have exact scientific data. I feel war-
ranted, however, in saying this much, that patients operated on
by the elastic ligature thrive very well on nutritive enemata for
the fifty hours which must elapse before they can take fluids by
the mouth. In the use of the elastic ligature for gastro-enter-
ostomy, simple as it is, the surgeon must inform himself of the
proper technique. He must, first of all, choose a proper rubber
cord. Rubber threads or weak rubber bands will not do; they
may, from sheer lack of strength, fail to accomplish their pur-
pose. For the same reason the ligature must be made of the
very best rubber. There are various grades of rubber in the
market.
The ligature which I first used, in 1891, was a cord two
millimetres in diameter. I put it aside for nine years, and then
when I took up the operation again I found it as strong and good
as ever. When I had used it up I could get no more, as, for
some unknown reason, it was no longer manufactured. I tried
in my last operation a smaller cord, which in that case answered
the purpose, but the rubber proved to be of poor quality, and a
few days afterward, as I was examining it, it broke in pieces in
my hands. At my request. Nelson, Baker & Co.. of Detroit,
had some manufactured of proper size from a first grade rubber.
These ligatures will stretch to six times their length without
breaking or suffering any impairment of their elasticity. They
can be obtained, if desired, from this firm. The best needles to
use with these ligatures are common large, darning needles.
They are round, and have large eyes, into which the ligature,
when shaved thin at the end, can easily be coaxed. When
VICIOUS CIRCLE AFTER G AST RO- ENTEROSTO M Y. 439
operating by this method the wall of the stomach or intestine
should be grasped in a fold and the needle thrust through the
base of the fold. By making traction on the ligature as the
needle is pulled through the cord is thinned and readily follows
its guide. Whatever length of tissue is desired for division
should be included in one ligature. When the ligature is passed
through both viscera it should be drawn tight with one turn of
the knot. A silk thread, previously placed in position, should
now be tied tightly around the knot, and the process repeated
with the second turn of the knot. Lembert stitches may be so
placed, outside and inside, as to hide the knots from view.
I am confident that a proper ligature placed in the proper
way and drawn sufficiently tight will never fail in its object.
It has not been my purpose in this paper to present an
exhaustive study of all the questions which arise in regard
to the causes, symptoms and treatment of the '^ vicious circle."
I offer it merely as a clinical study from which I have sought to
draw certain practical conclusions which will serve, perhaps, for
our present guidance, and be valid until new studies and new
methods make it desirable to change our practice. These con-
clusions may be stated as follows :
1. The "vicious circle" may occur whenever the duodenum
becomes permanently distended, even though the efferent limb
of the jejunum offers an open passage to the ingesta. In all
operations of this kind, therefore, entero-enterostomy should be
added to the gastro-enterostomy in order that the duodenum
may discharge its contents into the efferent portion of the
jejunum.
2. It may also occur from obstruction due to spurs, twists,
bends and other entanglements of the intestines. As such acci-
dents may arise from a too short afferent limb of the jejunum,
the anastomosis should always be made at such a distance from
the duodenum as would make trouble from this cause impossi-
ble. The practice of turning the bowel around in order to make
its peristaltic movements correspond with those of the stomach
has no practical advantage whatever in cases of pyloric stenosis,
but, on the contrary, complicates the operation and tends to
440 VICIOUS CIRCLE AFTER G A STRO- ENTEROSTO M Y,
form a trap in which the intestine may become entangled. It
may, beside, drag the wall of the stomach into a fold which
may obstruct the opening into the bowel. This method of join-
ing the viscera should be altogether discarded.
3. As the orifices of communication may, if made too small,
contract and become obliterated, the opening should be made at
least five centimetres in length. The effects of any resulting
spur formation will be obviated by the entero-enterostomy.
4. The safest and best method of operating is that by the
elastic ligature.
FlC. 2.
Showing abnormal position of left leg in sitting posture.
Fig. 3.
Showing abnormal position of left leg and prominence ot condyles of femur
in popliteal space.
Fig. 4.
Showing erect posture assumed by child. The right hip and knee are flexed;
the left limb rests on condyles of the femur.
Fig. 5.
Showing lordosis of spine caused by eiect posture
ANTERIOR DISLOCATION OF THE TIBIA TREATED
BY ARTHROTOMY.
By JOHN B. ROBERTS, M.D.,
PHILADELPHIA.
A LITTLE girl, aged five years, born after a hard labor, was
brought to me for deformity of the left knee by Dr. F. S. Nevling.
I found that the tibia was displaced forward on the femur, so that when
the child lay upon her back the tibia extended upward, making an
angle with the plane of the bed of about 50° or 60°. The small patella
could be felt in the hollow above the head of the tibia. The condyles
of the femur, with the popliteal artery beating between them, could be
felt at the posterior part of the joint close to the surface of the limb.
The child had learned to stand on both legs by bending the spine in
the lumbar region, so that there was a marked lordosis. The abdomen
was very prominent, and the costal cartilages of the ribs were thrust
forward in such a manner as to deform the chest. The girl's head
was large and suggested intellectual deficiency. The mother, how-
ever, stated that she was as bright as the other children, and had
learned to talk before the end of the first year. A skiagraph was taken
and showed the deformity to be that suspected — namely, anterior dis-
placement of the tibia. The mother says that the labor at the time
of the child's birth was a severe one, and that the presentation was a
breech.
On March 22, 1901, I operated under ether for the reduction of the
dislocation. A large horseshoe incision was made across the front of
the knee so as to turn up a large flap. The ligament of the patella
was divided by the angular incision, which is often used in lengthen-
ing the tendon of Achilles. The lateral ligaments of the joint were
divided almost, though not quite, completely. The dislocation was
then easily reduced. It was found impossible to unite the ends
of the ligament of the patella, though a third of an inch had been
442 ROBERTS,
gained by the manner of making the angular incision through it.
It therefore became necessary to lengthen the four-headed muscle
attached to the upper portion of the patella. This was done by
exposing the muscle through a longitudinal incision carried upward
on the front of the thigh from the original horseshoe incision. The
lower end of the muscle was dissected free from the surrounding
tissues, and a cut made across it from the inner side of the muscle to
about the middle. This allowed the ligament of the patella to be
drawn together perhaps half an inch more.
Strong chromicized catgut sutures, four or five in number, were
passed through the tendon of the quadriceps and the lower piece of
the ligament of the patella and the tissues in front of the tibia. Three
of these sutures went through the tendon of the muscle above the
patella, so that there would be less danger of the great tension tearing
them out. By means of these sutures the divided ligament of the
patella was brought nearly into apposition, while the tibia was kept
slightly flexed on the femur. The external wounds were sutured and
a catgut drain left in the outer side of the wound. The leg was then
enveloped in an aseptic gauze dressing and fixed by means of a
gypsum splint. On the 24th the temperature of the child was high;
the gypsum splint was then removed, the catgut drain withdrawn, a few
stitches cut, and the joint irrigated with warm sterile salt solution.
The next day the inner side of the wound and the upper extremity of
the cut over the patella were opened, because of the fear of infection,
which was suspected to be the cause of the rise in temperature. Irri-
gation of the wound with sterile salt solution was begun.
It subsequently became necessary to lay open practically the
whole wound and put a drainage-tube through beneath the patella.
The cause of the infection was not clear; but from this time the case
was treated by frequent irrigations with corrosive chloride solution,
and subsequently with formaldehyde solution. The wound slowly
closed, and the child was sent to her home in the country, at the end
of a number of weeks, with a straight limb, which, however, was
greatly restricted in motion at the knee-joint. It is probable that
under massage and careful passive motion of the joint a considerable
degree of mobility may be obtained. The desire of the parent to
take the child home prevented further careful supervision of the treat-
ment. There was a tendency, at the time I last saw the child, to mod-
erate external deviation of the tibia, producing a condition a little like
knock knee. I have advised the wearing of a brace on the leg and
ANTERIOR DISLOCATION OF TIBIA. 443
the use of massage. The skiagraph and photographs taken before
the operation show the deformity and the peculiar attitudes assumed
by the child in the endeavor to use the deformed limb in walking. I
believe that under careful orthopedic treatment the spinal curvature
due to the abnormal posture of the patient necessitated by the dislo-
cated knee could be greatly diminished. It is to be feared that she
will be unable to obtain this sort of surgical treatment in her home,
which is distant from large hospitals.
GIANT SACROCOCCYGEAL TUMORS.
An Account of One which Pursued an Atrophic Course.
By CHARLES A. POWERS, M.D.
DENVER.
In October, 1897, there came under my observation, through the
courtesy of Dr. P. V. Carlin, a male child, aged three months, who
presented an unusual growth in the coccygeal region. The tumor was
congenital, and at birth was said to have been practically of the pro-
portional size and shape which it had when I saw it, and to have pre-
sented the same general characteristics. The child was mature at
birth, at which time the parents were told that it would probably die.
The only attention which the mass received was ordinary cleanliness.
The child thrived, and at three months of age was quite as strong and
as well nourished as babies of that age usually are. It had not been ill.
Examination of the child when first seen revealed a very large
growth, occupying the sacrococcygeal region, extending laterally to
the buttocks and forward in front of the anus. The growth en-
croached upon the left buttock rather more than upon the right,
reaching well to the gluteal fold on the left side. It was irregularly
ball-shaped ; the entire mass was as large as the head of a child six
years old. The tumor measured seventeen inches in circumference.
The general consistency was soft. Below and in front it was markedly
cystic and fluctuating, while above and laterally it was firm, and in
places nodular. The firmer portion seemed attached to deep struc-
tures, and these more solid parts were thrown into large, irregular
folds, with deep creases between them. The skin over the tumor was
normal above and at the sides, but very thin and of a bluish-red over
the cystic parts. Large veins crossed the latter portions. The skin
was freely movable over the fluid portion of the tumor, but tightly
attached in the crevices above mentioned. The cystic portions swayed
with the movements of the child. Palpation of this gave the impres-
GIANT SACROCOCCYGEAL TUMORS. 445
sion of one or more large cysts and many small ones, with here and
there firm portions of tissue. Deep palpation failed to reveal a gap
in the bony structures. Digital examination of the rectum showed
nothing abnormal. The bowels had been regular and the movements
natural. There had been no abnormality of micturition. When the
child cried the upper lateral parts of the tumor were moved by the
gluteal muscles, but the tension of the mass itself was not changed.
There was neither paralysis nor anaesthesia of the lower extremities.
The size, shape and location of the tumor are very well shown in Figs.
I and 2.
Removal of the mass was not advised, as the tumor was too large and
the baby too young. Aspiration of the fluid contents was suggested,
but the parents did not take kindly to the thought, and it was not
urged.
The mother was asked to keep it very clean ; to wash it with dilute
alcohol and dust it with a simple dusting powder, protecting it well with
soft clothing. She gave it the best of care. •
Three months later the tumor was in about the same condition ;
there had been no appreciable change. Six months after this, or when
the child was about one year old, the fluid portions of the tumor seemed
to be less prominent. The tumor itself had rather less of a ball-shape.
It was beginning to get flat.
The child was seen at intervals of two or three months. The tumor
underwent progressive contraction ; the skin over it never broke; it
was never ulcerated. The boy had the usual diseases of childhood :
measles, whooping-cough, diphtheria, etc., but his physician said
that he came through them all without accident. He waxed strong
and hearty. "He is the strongest of my six children," said the
mother.
Figs. 3, 4, 5, and 6 show the condition in March, 1901, the child
then being three years and nine months old. At this time the tumor
was well flattened out, circular in outline, extending to the gluteal
fold on the left side, but not quite as far as this on the right side ;
anteriorly it went to the anal margin in the middle line and in front
of the anus on the right side. Above it was limited by the middle of
the sacrum. Its diameter was five inches ; in size it was somewhat
larger than a man's fist, well flattened out. The skin over it seemed
rather thick ; it was movable in places. Here and there it was thrown
into deep folds, and at these folds the skin was tightly adherent. At
446 POWERS,
the right extremity a hard nodule, an inch and a quarter long and
one-half inch wide, was plainly felt. This nodule or lump could be
bent slightly on itself. It moved freely on the deep parts, but the
skin over it was attached. The entire mass was movable. As the
child lay on its mother's lap and kicked its legs, the upper lateral parts
of the tumor moved, the skin over it being thrown into deeper folds.
The mass was nowhere tender or inflamed. It seemed to be solid
throughout. Rectal examination was negative.
This boy is well developed, strong and healthy. He plays about
like other youngsters of his age, and has no symptoms whatever refer-
able to the lower extremities. He runs about, lies on his back, and
sits like other children. He does not favor this portion of his body
in any way — in a word, except for its mere presence, this tumor gives
no general or local symptoms. The boy never seems conscious of it.
Some variety of congenital malformation of the sacrococcy-
geal region is very common. That most often seen is the simple
dimple or groove, the so-called fovea coccygea. Beyond this
we have the epidermoid fistula or pilonidal sinus, and a step
further brings the true dermoid. In this class also may be
placed sacculation of the cord connected with vertebral fissures,
spina bifida occulta.
All the foregoing are of single germinal formation. The
more complex growths are of double germinal substratum ;
complete or incomplete double formations, and parasitic cystic
mixed tumors (teratomata-embryoid tumors). I believe that
the case heretofore related belongs to the last class, and, while
it lacks histological confirmation, one may reason by analogy
from similar growths which have been pathologically examined.
These sacrococcygeal teratomata present the greatest diver-
sities of tissue. They form a class of tumors by themselves.
They are generally mixed, and in addition to the structure of
dermoids they may and often do present cysts lined with cili-
ated, flat or columnar epithelium, muscle fibre, nerve tissue,
intestinal remnants, bone and cartilage. Rindfleisch names
such a growth a '* histological potpourri." The region itself
presents as much diversity of structure as does that of the
face.
GIANT SACROCOCCYGEAL TUMORS. 447
Stolper' has recently given the subject careful attention. He
approaches it almost entirely from the genetic or histological
stand-point. He found that many cases of spina bifida are mul-
tilocular, and can be told from teratoid tumors only by micro-
scopical study; combination of both forms may occur. Stolper
afifirms that it has not yet been proven that the remnant of the
medullary canal, a persistent coccygeal vertebra, the neuro-
enteric duct, or Luschka's gland, may be the starting-point of
such a growth, though the possibility of this is not denied. One
thing is certain, and that is that teratoid tumors of the sacro-
coccygeal region unanimously show components from all three
of the germinal layers. Variations in the mode of growth are
responsible for the great disparity in the microscopical appear-
ances. The manifold coarse and fine structure, the indica-
tions of so many different organs, the cyst formation, the
differences in the epithelium in one and the same cyst are
readily explained by the assumption of a double germinal sub-
strata.
Fig. 7 is from a photograph of a remarkable case which was
under Stolper's observation, a giant sacrococcygeal tumor in a
child five months of age.
Stolper's observations seem to be confirmed by a recent case
reported by Hagen-Torn.- This concerns a very interesting
case of congenital sacral tumor, which, in addition to many
forms of intestinal tissue, contained sarcomatous and myxo-sar-
comatous degeneration. He considers it a malignant degener-
ation of a sarcomatous nature, which had its origin in a small,
double germinal malformation.
Phocas, of Lille,-^ reports two cases. One a five"year-old child
presenting a tumor twelve centimetres in breadth by eleven
centimetres in thickness, and a second child of twenty-two
months with a tumor forty-three centimetres in circumference,
the pedicle of which measured nine centimetres in breadth and
twenty-five centimetres in circumference. Both tumors were
1 Deutsch Zeitschrift fiir Chir., Band 1.
2 V. Langenbeck's Archiv, Band Ix., Heft 3.
■'' Bull, et mem. de la soc. de chir. de Paris, t. xxii. p. 847.
448 POWERS,
markedly cystic, and both showed the most diverse tissue con-
stituents. Extirpation was successful in both cases.
Phocas advises delay in these cases until the children reach
such age as to enable them to withstand operation. When the
tumors are very large it may be better to extirpate them in
multiple sittings.
Broca and Cazin^ made careful examination of two specimens,
one from a child of six weeks, the other from a child of four
years. Both operations were successful, and both specimens
showed sections of intestine, having about the diameter of a
goose-quill, laid down in the midst of large masses of small
cysts. The microscopical evidences of the intestine were char-
acteristic. The cysts were lined with ciliated epithelium. The
authors believe the tumors to have sprung from the neuro-
enteric canal.
Calbet" discusses six teratogenetic tumors at length, and ar-
rives at the conclusion that twin monstrosities and congenital
sacrococcygeal tumors belong practically in the same class, and
that microscopical investigation will show all possible stages
between the simplest and the most complicated growths.
Nasse^ reports on five congenital coccygeal tumors, each of
which had a ventral seat. Some of these operations were
exceedingly difficult ; the cysts reached so high in the pelvis
that they could not be extirpated m toto. The most diverse
tissues were found in these tumors: connective tissue, bone,
cartilage, flat muscle fibre, conglomerate glands, mucous cysts,
which showed in part ciliated epithelium and in places a trans-
ition from squamous to cylindrical epithelium. One of these
tumors was a simple dermoid. The author assumes that the
other four arose from the post-anal remains of the intestinal
tract. Nasse says that while teratomata of dorsal growth often
contain nerve tissue, those ventrally situated are generally
cystic.
Perman, of Stockholm,^ reports an operation on a five-months-
1 Revue d'Orthopedie, 1895, No. 6. « Th^se de Paris, 1893.
3 Centralblalt fiir Chir., v. 19, p. 1077.
* V. Langenbeck's Archiv, Band xlix., Heft 3.
Flc. I.
Congenital sacrococcygeal tumor ; child three months old.
Fig. 2.
The same.
Fig. 3.
The same at three and a half years of age.
Fig. 4.
I he same.
Fig. s.
The same.
Fig. 6.
The same. Figs. 3, 4, 5 and 6 are to be compared with
Figs. I and 2, in order to show the spontaneous contrac-
ture which the tumor has undergone.
Fig. 7.
Fig 8.
Fig. 9.
(JIANr SACKOCOCCYGEAL TUMORS. 449
old child who had a cystic sacrococcygeal teratoma the size of
a baby's head. The mass was limited below by the gluteal fold,
on the right side it reached to the trochanter major, and it
stretched some two inches across the middle line in the sacral
region. The skin over it was very thin and movable. On
operation several large cysts and many small ones were found,
together with masses of gliomatous tissue. Large nerve fibres
could not be demonstrated. Here and there cubical and cylin-
drical epithelium. The coccyx was pressed somewhat to the left
side, but no gap in the spinal column could be discovered. The
child recovered. From the presence of the large amount of
gliomatous tissue Perman assumes that the structure came from
the same embryonal tissue as the brain and spinal cord.
Ritschl' removed a tumor the size of a child's head from the
sacral region. The mass was found to be made up of many
different tissues, in part cystic and in part solid. " Character-
istic fetal rudiments."
Other and similar observations might be cited, but I believe
that the foregoing tend to strengthen the assumption that the
case which I report may properly be placed in the class of tera-
tomata and embryoid growths. Its appearance at birth and a
few months thereafter, its partly cystic and partly solid nature,
its size and seat, all place it in line with the cases histologically
examined by Stolper and others. However instructive it might
be to add the pathological report, I am quite content to have
had the tumor undergo spontaneous contraction. The age,
size, and strength of the child, the absence of local pain, ten-
derness, and ulceration, the progressive shrinkage of the tumor
itself, all lead me to hope that nature may have cured the con-
dition. It is possible that further growth may take place, and
that malignant degeneration may ensue as time goes by. I am
unable to obtain record of any case in which a similar tumor
has pursued the course of this one.
1 Beitrage zur klin. Chir., Band viii.
Am Surg
CICATRICIAL STRICTURE OF THE CESOPHAGUS.
GASTROSTOMY, WITH RETROGRADE DILA-
TATION OF THE STRICTURE BY
RUBBER TUBES.
By henry R. WHARTON, M.D ,
PHILADELPHIA.
Robert N., aged seven years, was admitted to the medical ward
of the Children's Hospital, October 13, 1900, with the following
history : Four weeks before his admission he had swallowed a solution
of lye, which was immediately followed by difficulty in swallowing
and vomiting; these symptoms persisted, and he gradually lost
strength and weight, and at the time of his admission weighed only
twenty-seven pounds.
x\ttempts to pass an oesophageal bougie were unsuccessful. He was
also made to swallow several small silver shot attached to fine silken
threads, in hope these would pass the obstruction.
He was transferred to the surgical ward on December 8th, and
upon examining the oesophagus with a bougie I found that its point
was arrested at a point nine inches below the incisor teeth, and it
was found impossible to pass even the smallest bougie. He was
nourished at this time largely by nutritious enemata.
As he was gradually losing weight, gastrostomy was performed on
December 19th, the walls of the stomach simply being sutured to the
edges of the abdominal wound by deep sutures, and a fair-sized
opening made into the stomach. I then endeavored to pass a small-
sized bjugie through the stricture from the cardiac orifice of the
stomach, but was unsuccessful. The patient was nourished for some
time by food introduced through the artificial opening, and gained
gradually in weight.
Several weeks later he was etherized, and a No. 2 flexible English
catheter was passed through the stricture from the mouth, and its
CICATRICIAL STRICTURE OF THK CESOPHAGUS. 45 I
point, guided by the finger in tlie stomach, was brought out of the
artificial opening in the stomach ; to this was attached, by a strong silk
ligature, twelve inches in length, a small rubber drainage-tube, which
was drawn through the stricture by withdrawing the catheter, the
tube being well stretched as it was drawn through the stricture ; the
tube was drawn upward until its upper extremity was well up in the
oesophagus. A silk ligature was next tied to the lower extremity of
the rubber tube, and its ead was allowed to drop back into the cavity
of the stomach. The ligature projecting from the mouth was then
secured to that passing out of the opening in the stomach. The
stricture was dilated at intervals of a few days by attaching larger
rubber tubes to the ligature passing from the opening in the stomach,
and by allowing the tubes, which were drawn through the stricture
under tension, to remain for a few days, fair dilatation of the stricture
was accornplisiied. After removing the rubber tube it was found pos-
sible to pass bougies from the mouth through the stricture, gradually
increasing their size. It was found, however,' that as the patient
began to take nourishment by the mouth, a considerable amount
of it escaped from the fistula, and he again began to lose weight,
which was at this time twenty-six pounds.
I next decided to close the gastric fistula, which was done by
making an elliptical incision around the gastric fistula, about an
eighth of an inch from its edges ; the tissues were next dissected
loose close to the fistula and invaginated, so that the raw surface of
the flaps came in contact; these were secured in this position by six
silk sutures. The inverted flaps were then covered by dissecting
flaps from the outer edge of the incision and sliding them over the
position of the opening and securing them by sutures. The patient
did well after this operation, and the fistula closed.
The patient is now taking nourishment well by the mouth, and has
gained in weight, now weighing thirty-eight pounds. The dilatation
of the stricture is still practised at intervals of a few days.
Remarks. The great majority of strictures of the oesophagus
occurring in children result from the swallowing of lye. All
strictures of the cesophagus which have come under my obser-
vation have resulted from this cause, with two exceptions. In
one case the stiicture followed an attack of diphtheria, and in
the other it occurred as a sequela of typhoid fever. Professor
45 2 WHARTON,
Alex. Johannersen/ of Christiana, reports 140 cases of lye-
poisoning in children, and V. Torday,^ of Budapest, reports 70
cases of the same affection coming under his personal observa-
tion. The frequency of this accident in the countries from
which these cases are reported is accounted for by the fact that
lye, either in the solid form or in concentrated solution, is
largely used for domestic purposes in the place of soap.
In Johannersen's 140 cases the mortality was 8.6 per cent.,
the causes of death being acute poisoning (intoxicatia alkalina),
six; perforation of right pleura (from sounding), one; hemor-
rhage from mouth (cause unknown), one ; bronchopneumonia,
one ; empyema, one ; noma, one ; purulent pericarditis, pleu-
ritis, and pneumonia, one each.
In 74 cases a stricture of the oesophagus resulted. In 104
cases in which bougies were passed, 53.8 per cent, were cured
by dilatation, being dilated sooner or later to 30 Chariere scale.
In 46.2 per cent, some narrowing of the oesophagus remained in
spite of sounds passed by the mouth, 3 cases being impassable ;
others were permeable by sounds varying from No. 10 to No. 29.
Two of the fully dilated cases died. Two experienced recon-
traction. Of the 48 cases not fully dilated or impassable, i died
from perforation of the right pleura, 3 had gastrostomy per-
formed, with 2 recoveries and i death ; i case had external
cesophagotomy performed, with a favorable result.
The same authority mentions 46 cases collected by Keller,
with a mortality of 14.3 per cent., 76 per cent, of these cases
having had well-marked stricture of the oesophagus ; of these
65.7 per cent, were cured, 3 improved, 5 died, and in the remain-
der the ultimate result was unknown. In Hacker's collection
of 333 cases, 52.2 per cent, had strictures, and 26.4 per cent,
died. In Van Falck's 27 cases, 81.5 per cent. died. In Lewin's
89 cases, 60 per cent. died. Robert estimates the mortality
from cicatricial stricture of the oesophagus at from 60 to 80
per cent.
It is difficult to estimate definitely the mortality, as the ulti-
mate result in many cases cannot be ascertained. V. Torday, in
• Jahrbuch f. Kinderheilkunde, February 6, 1901. '^ Ibid., 3d series, Band liii.
CICATRICIAL STRICTURE OF THE QiSOPHAGUS. 453
70 cases of cicatricial stricture of the (L-sophagus resulting from
the swallowing of lye, excluding those who died of perforation,
states that 6 died of intercurrent disease, 3 were removed by
parents without treatment, 30 were dilated to 15 English scale,
12 to 12, 5 to II.
Stricture of the oesophagus following lye results, sooner or
later, in a large majority of the cases, occurring in 74 per cent,
in Johannersen's cases, and j^ per cent, of Keller's, and in 52.2
per cent, of Hacker's cases. The methods of treatment which
are employed for the cure of cicatricial stricture of the
oesophagus, are (i) gradual dilatation by bougies; (2) tubage ;
(3) oesophagotomy, internal or external ; (4) gastrostomy, fol-
lowed by the " string " method, and dilatation with elastic tubes,
and sometimes combined with cesophagotomy.
1. Gradual dilatation by bo2tgics is the safest method, and if
employed early is very successful. This operation is not
entirely free from danger, as one of Johannersen's cases died
from perforation of the pleura in passing a sound, and in 120
cases reported by Torday, in which dilatation was practised,
eight perforations occurred, giving a mortality of 6.6 per cent, by
this method. This accident seems to be more common in cases
of stricture of some standing in which diverticuli have formed
above the strictures. Torday considers that the prognosis in
cicatricial strictures of the oesophagus in children is favorable,
as the gradual growth of the oesophagus favors the artificial
dilatation of the stricture if the stricture is not annular.
In 104 of Johannersen's cases in which dilatation by bougies
was practised, 53.8 per cent, were cured, while in 46.2 per cent,
some narrowing remained. In view of the mortality which has
occurred from perforation with the bougie during dilatation, it
is important that the greatest care and gentleness should be
exercised in its passage.
2. Tubage. This consists in the passage of specially con-
structed hard-rubber tubes of different sizes and lengths through
the stricture. These are introduced by an instrument through
the stricture, and are allowed to remain in place as an intuba-
tion-tube is allowed to remain in the larynx. They have been
454 WHARTON,
employed to some extent in the malignant strictures of the
oesophagus, btat I am not aware that they have been used in
cicatricial strictures following the swallowing of lye, although,
in properly selected cases, they might be employed with
advantage.
3. CEsvphagoiomy, internal or external^ has been employed in
a number of cases with success, but this operation is only
applicable to strictures involving the upper portion of the
oesophagus. This operation is sometimes combined with
gastrostomy.
Johannersen records i case of external cesophagotomy with
a favorable result. Torday records 15 oesophagotomies for
cicatricial stricture of the oesophagus, with the following results :
In 8 cases in which external cesophagotomy alone was prac-
tised, four died and four recovered. In 2 cases of external and
internal cesophagotomy, two recoveries occurred. In 5 cases in
which cesophagotomy and gastrostomy were combined, five
recoveries took place. In 3 cases in which internal cesopha-
gotomy alone was practised, two died and one recovered.
4. Gastrostomy. The operation of gastrostomy may be
required as a means of nourishing the patient and also to gain
access to the stricture for its treatment. The modern operations
of gastrostomy, such as Witzel's, or Ssabanejew-Frank's, which
aim to prevent leakage from the fistula in the stomach, cannot
be employed with advantage in the treatment of stricture of the
oesophagus, as they do not permit of the introduction of the
finger or instruments into the stomach for this purpose. We
therefore generally have to resort to the old method of gas-
trostomy, which simply secures the walls of the stomach to the
edges of the abdominal wound, or the method of gastrostomy
which was described by Stamm, and which was employed suc-
cessfully by Curtis in a case of stricture of the oesophagus. This
method possesses the advantage of preventing leakage, even
when a string is present in the fistula. Stamm's' method con-
sists in inserting the catheter through a small opening made
• Medical News, September 22, 1894.
CICATRICIAL STKlCrURE OK THE CESOPHAGUS. 455
in the stomach, and then inverting the wall of the latter in
a funnel-shaped manner by two purse-string sutures surround-
ing the opening. The first suture is passed about half an
inch from the edge of the opening, the needle picking up only
the outer coats of the stomach, making a complete circle
around the opening. The stomach-wall within this circle is
inverted and the suture tied so as to pucker up the tissues
around the catheter. A similar suture is then passed half an
inch from the first, and secured in the same way, and next both
ends of the purse-string suture are armed with needles and
passed through the entire thickness of the abdominal walls on
both sides of the wound and tied in a loop. Thus there results
a nipple-like protrusion of the wall of the stomach inside the
organ around the catheter, which acts as a valve and prevents
the escape of the contents of the stomach when the tube is
withdrawn. The fistula thus formed usually closes spontane-
ously when no longer required.
The disadvantage of a gastric fistula made by the old method,
if it is large enough to permit of the manipulation with instru-
ments or the finger, is it is apt to be followed by leakage, which
may be so free that the patient does not retain sufficient nour-
ishment. When a gastric fistula has been established attempts
should be made to pass a small bougie from the mouth through
the stricture into the stomach, or to pass it from the cardiac
orifice of the stomach through the stricture, and bring it out of
the mouth. Retrograde dilatation by bougies or rubber tubing,
as was practised in this case, can often be accomplished when
it is found impossible to pass an instrument by the mouth, this
probably being due to the fact that a diverticulum exists which
prevents the passage of an instrument by the mouth. When
this bougie has been passed a strong silk ligature is attached
to its end, and it is drawn through the stricture ; the method
of Abbey can then be practised, which consists in sawing the
stricture by means of the string, one end of which is held in the
mouth, and the other end of which is held by the finger inserted
into the stomach ; after the stricture has been slightly enlarged
in this manner it is subsequently treated by dilatation with
456 CICATRICIAL STRICTURE OF THE CESOPHAGUS.
bougies. Another method consists in attaching a small rubber
tube to either the end of the string protruding from the
stomach or that protruding from the mouth, and drawing it
through the stricture under tension, and allowing it to remain
in position for twenty-four hours, so that by exerting elastic
pressure upon the walls of the stricture dilatation may be
accomplished. When the rubber tubing has once been passed,
the string, by means of which it has been drawn through the
stricture, should be secured to the other end of the tubing. If
the tube is drawn from the stomach upward the upper extremity
of the tube should not pass beyond the lower portion of the
larynx, so that the silk thread only protrudes from the mouth,
which is less likely to produce gagging than if the tube occu-
pies this position. Rubber tubing, gradually increased in size,
is passed at intervals of a few days until the stricture is suffi-
ciently dilated to allow the passage of a fair-sized bougie.
After this has been accomplished, the dilatation can be kept up
by the passage of bougies, and the patient can take a sufficient
quantity of nourishment. The gastric fistula may be allowed
to close spontaneously, or be closed by a plastic operation.
Johannersen records three gastrostomies in his collection of
cases, with two recoveries and one death. Torday has collected
26 cases of cicatricial stricture of the cesophagus in which gas-
trostomy was performed. In 19 cases of simple gastrostomy
there were twelve recoveries and seven deaths, the latter being
due to peritonitis and other complications. Two cases recov-
ered, but had a permanent gastric fistula.
In 5 cases of gastrostomy combined with cesophagotomy
there were 5 recoveries.
MOVABLE KIDNEY : ITS CAUSE AND TREATMENT.
By M. L. HARRIS, M.D.,
CHICAGO. •
The kidneys are usually classed as fixed organs. They,
however, are not fixed, but possess normally quite a range of
motion. This varies from two to four centimetres in a longi-
tudinal direction, and corresponds to the rise and fall of the
diaphragm during respiration. As a rule, the normal kidney
cannot be palpated through the intact body walls in men,
but in women the right can be distinctly felt in a majority
of the cases, and the left in a smaller proportion. A kidney
may often be easily palpated by one with much practice, when
another with less experience would fail to perceive it.
In palpating a kidney the patient, with all clothing about the
body removed, should lie on the side opposite the organ sought,
with the head and shoulders slightly higher than the hips, and
the thighs gently flexed. Standing-at the back of the patient,
the fingers of one hand are firmly pressed against the abdotni-
nal wall just below the costal arch and to the outer side of the
rectus muscle, while, with the fingers of the opposite hand, firm
counter-pressure is made against the small triangular space just
below the twelfth rib behind. The patient should take a deep
breath, during the somewhat rapid exhalation of which the
kidney, if palpable, may be grasped between the two hands.
This lateral position has been found preferable, as a rule, to the
standing position, for the reason that many patients, even with
the body bent forward and the weight resting on a table, are
unable to relax the abdominal muscles as completely as when
lying on the side. It is often possible to palpate a kidney in
458 HARRIS,
the lateral position which could not be felt with the patient
lying on the back.
For the sake of clearness, it is necessary to define what is
meant by a palpable and movable kidney. In almost every
individual not possessed of more than the average amount of
subcutaneous fat the kidney may be felt in the sense that, with
the one hand firmly pressed in the triangular space below the
twelfth rib behind, while deep pressure with the other hand is
made in front, and the patient take a deep breath, an indistinct
mass will be felt to impinge against and recede from the hand
placed posteriorly. Such a kidney, however, is not said to be
palpable. Only when a portion of the kidney can be distinctly
grasped and outlined between the two hands is it said to be pal-
pable. One-third, one-half, or two-thirds of the kidney may
thus be palpated. In case more than one-half of the organ can
be outlined, and it can be caused to recede out of reach during
exhalation, it is said to be movable to the first degree. In case
both hands can be brought together above the organ, it is
movable to the second degree, and if it can be depressed to
the pelvic brim or moved to beyond the mid-line, it is movable
to the third degree.
This classification is, of course, arbitrary, but of value in
facilitating clearness of description. The great frequency of
movable kidney in women has only recently been realized
owing to a more systematic examination of patients with this
point in view. Kiister^ found that the 4.41 per cent, of the
women in his general surgical practice had movable kidneys,
while Edebohls, in an exclusively gynecological practice, esti-
mates that 20 per cent, are thus afflicted. As will be seen
from the subjoined table, both of these figures are very
much too low, as my figures show that 56 per cent, of the
women had distinctly movable kidneys on one or both sides.
What are the causes of this large percentage of movable
kidneys in women ? The etiological factors usually mentioned
are the following :
' Deutsch Chir. Lief, 52 B.
MOVABLE KIDNEY. 459
Repeated pregnancies, which are supposed to act by pro-
ducing a relaxation of the anterior abdominal walls, thus dimin-
ishing the abdominal pressure against the kidneys, as well as
by the large uterus directly displacing these organs ;
Prolapse of the uterus and vagina, with lacerations of the
perineum by contributing to the reduction of intra-abdominal
tension ;
Retrodisplacement of the uterus by drawing on the ureters ;
The rapid absorption of the perirenal fat, as may occur in
acute wasting diseases ;
Drawing on the kidneys by the transverse mesocolon in
enteroptosis or Glcnard's disease;
The relaxation of the abdominal walls which follows the
removal of large intra-abdominal tumors or ascitic accumu-
lations.
That these factors have very little or no influence in giving
rise to movable kidneys will be clearly shown.
The fallacy of supposing that pregnancy, lacerations of the
perineum, displacements of the uterus, etc., are instrumental in
causing movable kidneys is unanswerably shown by the fact
that over 40 per cent, of the cases of movable kidneys were
found in unmarried women ; in women who have thus never
been pregnant, who have intact perineal floors, and whose uteri
are in normal position. That these factors may, and perhaps
at times do, aggravate the condition caused by other influences
is admitted.
The fallacy of the theory of the absorption of the perirenal
fat has been shown by Heller, and of the traction theory by
Ewald. The influence of traumata, both internal and external,
will be considered later. What, then, is the fundamental cause
of movable kidney? This is found in the relation which exists
between the location of the kidney and the body form.
The exhaustive work of VVolkow and Delitzin renders it
unnecessary to enter into a study of the location of the kidney
as found in the dead-house. Conclusions, however, based
entirely on dead-house findings are erroneous, for the reasons
that when the body is in the recumbent position the kidney
460 HARRIS,
assumes its highest or most cephalad location; that this loca-
tion is moved still further cephalad by the final contraction
of the chest at death, and last, because the kidney loses much
of its mobility owing to the post-mortem solidification of the
perirenal fat.
These studies are, therefore, based upon observations made on
the living subject in the examining-room and on the operating-
table. While systematically examining patients in Litten's clinic,
Becker and Lennhoff^ became convinced that they were able to
predict from the general appearance of the body-form of a
woman whether the kidneys would be found palpable or not.
In order to reduce this conviction to some tangible shape a
series of measurements of the women examined was made,
which eventuated in what they termed the index of the body-
form. This index was obtained by dividing the distance from
the suprasternal notch to the upper edge of the symphysis
pubis by the least circumference of the abdomen and multiply-
ing by 100. They found that in women with a high index the
kidney was usually palpable, while in those with a low index
it was not palpable. The average index was seventy-seven.
They therefore divided the patients into positive, or those
with an index above seventy-seven, in whom the kidney could
be felt; and negative, or those whose index was below seventy-
five, and whose kidneys could not be felt. Before the appear-
ance of Becker and Lennhoff's article I had made some obser-
vations on the body-form in its relation to the kidney, which
were inspired by Kiister's article in 1895, on the cause of sub-
cutaneous lacerations of the kidney and of movable kidney.'
Kiister's observations I was able to confirm many times during
my course on operative surgery on the cadaver as well as by
observations on the living subject. I then began a more sys-
tematic study of movable kidneys and the location of the
kidney in its relations to the body-form, or rather the influence
of the body-form on the location of the kidney.
' Deutsch med. Woch., 1898, xxiv., S. 508.
'•^ Arch. f. kliii. Chir., 1895, No. 50, S. 676.
MOVABLE KIDNEY. 461
In this study certain measurements of the body were taken,
together with certain other data, which were supposed might have
a bearing on the subject. It was soon found that the measure-
ments taken by Becker and Lennhofif, namely, the jugulo-
symphisis and the least abdominal circumference, were not
sufficient to give one a correct idea of the body-form, nor did
these measurements offer, in any way, an explanation of the
fact that in certain cases the kidney would be found palpable,
while in other cases it could not be felt. Numerous exceptions
to their rule, as shown by themselves, also indicated that there
were other factors which should be taken into consideration.
In order to determine what those other factors were, additional
measurements of the body were taken, together with the fol-
lowing data: Sex, age, married or single, number of children,
weight, height, condition of the tenth rib, accidents, such as
severe falls or injuries to the body, and the condition of the
pelvic organs and perineum.
For purposes of this study the body cavity may be sub-
divided into three portions or zones, the upper of which con-
tains chiefly the lungs and heart; the middle zone, the liver,
stomach, spleen, pancreas, and major portion of each kidney;
while the lower zone contains the intestinal canal and a minor
portion of each kidney. The true pelvis may be disregarded.
A transverse plane, passing through the body at the lower end
of the sternum proper, not the xiphoid appendix, forms the
lower boundary of the upper zone, and a similar plane, which
cuts the lowermost point of the tenth rib, forms the lower
boundary of the middle zone. While the plane forming the
boundary between the upper and middle zones does not, of
course, accurately separate the chest from the abdomen, it may
be taken as such for practical purposes, and has been found to
be of great importance in determining the body-form and in
estimating the capacity of the middle zone, as will be shown in
the table of measurements.
After measuring the least abdominal circumferenoe in a num-
ber of individuals it was found that this plane was not fixed in
regard to its location ; thus, in women, while it usually cut the
462 HARRIS,
tenth rib. it often passes below this point, and occasionally was as
high as the ninth rib. In children it usually passes entirely below
the ribs, often as much as one centimetre, and in men it usually
passes just below the tips of the eleventh and twelfth ribs. It,
therefore, soon became evident that this measurement should be
taken at some fixed point in order to obtain reliable comparative
results. As the middle zone includes that portion of the body
cavity which is partially inclosed by the lower ribs, its lower
boundary should correspond with the lowest point of these ribs.
The tenth rib is the one which forms the lowest point laterally,
and in measuring the circumference of the body at this point, the
tape should always rest on the lower edge of the tenth rib at its
lowest part instead of measuring the least abdominal circumfer-
ence without regard to its location.
In taking these measurements the patient should lie flat on
the back. If the shoulders are raised any, it is very easy to
shorten the jugulo-symphysis distance one to three centimetres,
owing to the forward curve of the body. The circumference of
the body at the tenth rib is first taken, and the point where this
line crosses the middle is marked with a pencil. The lower end
of the sternum or apex of the costal arch is marked, and the
circumference of the body at this point measured. The breasts
should be drawn upward so as not to include the lower part of
them in the measurement. Both of these measurements should
be taken at the end of expiration during ordinary respiration.
The jugulo-symphysis is the distance from the upper end of the
sternum or suprasternal notch to the upper border of the sym-
physis pubis. In taking this measurement, the length of each
zone, upper, middle, and lower, should also be separately re-
corded. By dividing the jugulo-symphysis b}^ the circumference
at the tenth rib an "index" was obtained, which, in the table, is
marked "Index No. i."
In measuring the circumference in the manner just mentioned
several sources of error were observed which vitiated somewhat
the results, and occasionally made them appear contradictory.
Thus it was found in measuring the abdominal circumference
that the deposit of fat which rounds out the female form above
MOVABLK KIDNEY. 463
the hips was occasionally so great that the circumference was
increased out of proportion to the inner capacity. The same
effect was produced by the muscles of the loin in some women
in whom a marked constriction of the lower ribs is present.
The measure is increased if taken when the stomach is full or
distended.
In women with a lax or pendulous abdomen with visceral
ptosis, the lower ribs spread considerably when the patient is
lying down, and the circumference is thus increased from two to
five centimetres over the same when standing. In a well-built
person with firm muscles the circumference when lying differs
little or not at all from the same when standing. In case the
breasts are quite large, even when drawn up as much as possible,
the circumference of the body at the lower end of the sternum
is increased out of proportion to the inner capacity.
As the object of the measurements is to- form therefrom an
idea of the relative capacity of the middle zone of the body, it
may be readily seen that in the cases just mentioned an errone-
ous conclusion maybe drawn. Some method of measuring was
therefore sought which would eliminate these errors. This was
found in the use of a graduated calipers.
By means of the calipers certain diameters of the body could
be measured opposite fixed points, which are less influenced by
varying amounts of adipose tissue and other conditions of the
body. The measurements, taken with the calipers, are five in
number, namely :
No. I. Lateral diameter of the body on a plane correspond-
ing with the lower end of the sternum. This plane at its widest
lateral diameter usually cuts the seventh rib, and the ends of the
calipers are therefore pressed against these ribs and the widest
diameter recorded. This measurement is called the upper lateral
diameter.
No. 2. Is the middle lateral diameter and is the greatest dis-
tance between the lower edge of the tenth ribs. Care should
be taken to place the ends of the calipers against the lower por-
tion of the tenth ribs and avoid the muscular folds often present
in this region.
464 HARRIS,
No. 3. The lower lateral diameter is the widest distance
between the crests of the ilia.
No. 4. The upper antero-posterior diameter extends from the
lower end of the sternum to the spinous process directly oppo-
site and in the same plane as the upper lateral diameter.
No. 5. The middle antero-posterior diameter extends from
the mid-line in front to the spinous process opposite, and in
the same plane as the middle lateral diameter.
These measurements should be taken with the patient stand-
ing.
The cases in which these last measurements were taken in
women are placed by themselves and labelled " Second series."
These five measurements present a formula which may be said
to represent each a particular body-form. By dividing the
middle lateral diameter by the upper lateral and multiplying by
100 is obtained what is called " Index No. 2." By a careful
consideration of these tables it is found that many important
and interesting conclusions may be deduced therefrom.
As women are the most frequent sufferers from movable kid-
ney they will be considered first. The cases are arranged in
order, based on" Index No. i," beginning with the lowest index
and ascending to the highest. In the " Second series" the same
order is maintained, and next to " Index No. i" is placed " Index
No. 2 " The indices are simply attempts to reduce to single
figures the relations between certain of the body measurements,
and thus represent at a glance the body-form.
"Index No. i" shows the relation which exists between the
length of the body cavity and its circumference at the lower
edge of the tenth rib. " Index No. 2" refers entirely to the
middle zone of the body, and shows the relation which exists
between the lateral diameter of the lower end of this zone and
that of the upper end, or, in other words, the amount of con-
striction or diminution of the capacity of the lower end as
compared with the upper.
It will be observed that the column marked " Index No. 1"
is arranged in ascending order, and that the location or condition
of the kidneys, as noted in the proper columns, is found to be
MOVABLE KIDNEY. 465
" negative" or not palpable until the index reaches "j"] to 78. In
those cases in which the index is above this point, either one or
both kidneys are found to be palpable or movable to a greater
or less degree. The exceptions to this rule will be noted later.
If all cases be divided into " negative" and " positive" there will
be found among the women fifty-five negative and seventy-one
positive.
That all cases with a low index are uniformly negative and
those with a high index uniformly positive cannot be due to
chance. An explanation of this fact will be found in a study
of the other measurements given in the table. Weight is found
to favor the negative cases, their average weight being 58.7 kg.,
while that of the positive is 54.5 kg. In height the positive
exceed the negative by 2.4 cm., their average heights being
respectively 160.4 cm. and 162.8 cm. Of this increase in height
one-half or 1.2 cm. lies in the length of the body or jugulo-
symphysis and the remainder in the extremities. Average
jugulo-symphysis is 50.82 negative and 52.03 positive.
The interesting point in this connection is the distribution of
this 1.2 cm. in the different zones of the body. The average
length of the different zones are : upper zone, 14.55 cm. for the
negative and 14.58 cm. for the positive; middle zone, 14 cm.
for the negative and 15. i cm. for the positive; lower zone, 22.27
cm. for the negative and 22.33 cm. for the positive. It will thus
be seen that the lengths of the upper and lower zones remain
about the same in the two classes of cases, while practically
the entire increase in the length of the jugulo-symphysis in the
positive cases over the negative is found to lie in the middle
zone.
If we now consider the average circumference of the middle
zone at its upper and lower portion, we find this to measure 77.1
cm. for the upper and 69.5 cm. for the lower in the negative
cases, and 73.46 cm. for the upper and 61.9 cm. for the lower
in the positive cases. This is a difference of 7.6 cm., or 9.8 per
cent., in the negatives, and 11.56 cm., or 15.7 per cent., in the
positives. This shows that there is a marked increased contrac-
tion or diminution in size of the lower portion of the middle
Am Surg 30
466 HARRIS,
zone in the positive cases over that in the negative. This will
be still better shown when we consider the diameters taken with
the calipers.
If the middle zone were a true conic section, with a greater
and smaller circumference, as above given, the middle zone in
the positive cases would contain nearly 800 c.c, or 132 per
cent, less than the same in the negative cases. This would be
equivalent to the space occupied by both kidneys and the spleen.
Of course, in this estimate no allowance has been made for the
thickness of the body-wall, nor for the marked difference between
the configuration of this section of the body cavity and the
external surface. It simply demonstrates that there is a marked
contraction of this space in the positive cases as compared with
the negative. As already pointed out, certain slight errors may
occur in measuring circumferences which are practically elimi-
nated by measuring the diameters with graduated calipers.
If we consider now these diameters we find that in the nega-
tive cases the average upper lateral diameter is 23.62 cm.; aver-
age middle lateral diameter, 20.2 cm. ; average lower lateral
diameter, 28.7 cm. ; average upper antero-posterior diameter,
16.9 cm.; average middle antero-posterior diameter, 15.67 cm.
In the positive cases the average corresponding diameters are :
Upper lateral
. 23.85 cm
Middle lateral
. 17.44 "
Lower lateral ......
. 29.06 "
Upper antero-posterior ....
• 1703 "
Middle antero-posterior ....
. 14.26 "
The difference between the upper lateral and the middle late-
ral in the negative is 3.42 cm., or 14.4 per cent., and the differ-
ence between the upper antero-posterior and middle antero-
posterior is 1.23 cm., or 7.28 per cent., while the difference
between the upper and middle laterals in the positives is 6.41
cm., or 27 per cent., and between the upper and middle antero-
posterior 3.04 cm., or 17.5 per cent. This shows that the mid-
dle zone diminishes in size from above downward nearly 100
per cent, more from side to side, and 140 per cent, more from
MOVABLE KIDNEY. 46/
before backward in the positive cases than it does in the nega-
tive.
If we compare corresponding diameters in the two classes of
cases we find that the upper laterals are practically the same,
while the positive middle lateral is 2.76 cm., or 13.6 per cent,
smaller than the negative. In the upper antero-posterior there
is a slight increase, 2.3 per cent., in favor of the positive, and
in the middle antero-posterior a diminution of 1.41 cm., or 9
per cent., in favor of the positive. If we figure the area of the
lower end of the middle zone we find that it is 21 per cent,
smaller in the positive cases than it is in the negative. This
diminution in size is equivalent to displacing downward the
contents of this space 2.6 cm. at its lower end.
It will thus be seen that these measurements, however figured,
demonstrate beyond dispute that in those cases in which we
find movable kidneys there is a marked diminution in the
capacity of the middle zone in which the major portion of the
kidney should lie, and that this diminution increases in ratio
from above downward.
As the chief and characteristic peculiarity of these cases lies in
the marked difference in size between the upper and lower ends
of the middle zones, the ratio which the one bears to the other
may be used as an index to express the particular body-form ;
the ratio of the areas would be the more correct. However, as
it requires considerable figuring to determine this, it has been
found much simpler to use the ratio of the middle lateral diam-
eter to that of the upper lateral. It corresponds very closely
to the ratio of the areas, and is determined by dividing the
middle lateral by the upper lateral diameter and multiplying by
100. This constitutes what I have called " Index No. 2," and
is more reliable than " Index No. i." The average Index No. 2
for the negative cases is 85.26 and for the positive 73.23.
In consulting the tables we find that all cases with an index
above 81.8 are negatives, and all below this number are positive.
We find in the table two cases, Nos. 100 and 121, with the same
index, namely, 81.8, one of which is positive and the other neg-
ative. In looking at the antero-posterior diameters, however,
468 HARRIS,
we find a contraction of from 18 to 14 or 22 per cent, in the
positive, and only from 17 to 16 or 6 per cent, in the negative,
which explains the difference very nicely. Had the areas been
used, instead of simply the lateral diameters, the indices would
not have been the same. These two cases also illustrate the
fact that while the index represents briefly and in a general
way the body-form, it does not take into consideration all the
points, and is, therefore, not entirely reliable. If all the meas-
urements be considered, and particularly the five taken with the
calipers, a formula will be obtained which represents accurately
the body-form.
Case No. 98 shows an error which may arise in measuring
the circumference and relying on Index No. i. In this case
the deposit of fat above the hips was very marked and the cir-
cumference correspondingly large. This gave a low Index No.
I, namely, TZ-l^ which should indicate a negative case. The
right kidney, however, was very easily found and freely mova-
ble to the second degree. If we consider the diameters as taken
by the calipers, which eliminate the error of fat, we find the mid-
dle zone contracted from 28 cm. above to 20 below, a difference
of nearly 28 per cent., and explains at once the cause of the
movable kidney. Other apparent exceptions are thus readily
explained when all the measurements are taken into consider-
ation.
In what manner does a diminution of the capacity of the mid-
dle zone bring about a movable kidney? As already shown,
the upper zone remains on the average practically the same in
the two classes of cases. Any lessening of the capacity of the
middle zone must, therefore, result in a displacement of the con-
tents of this space downward. The liver is affected first, and as
it is depressed its posterior border acts immediately upon the
right kidney, tending to displace its superior pole forward or to
depress the entire organ. The presence of the liver explains
the great predominance of involvement of the right kidney. The
left kidney is not only somewhat more firmly fixed, but has
pressing upon it only the small spleen and the soft, yielding
MOVAULE KIDNEY. 469
Stomach. Although this depression of the kidney is always
present as the principal determining cause, it is not the entire
cause of movable kidney. The kidney is so far depressed that
the constricted and narrow outlet, as it may be called, of the
middle zone is above the centre of the organ, so that every
movement or action of the body which tends to still further con-
tract this outlet by adducting the lower ribs produces pressure on
the upper portion of the kidney and constantly tends to press it
downward. The amount or degree of mobility depends, there-
fore, not alone on the amount of constriction of the middle zone,
but on the many conditions, such as heavy lifting, hard work,
straining, coughing, flexions of the body, etc., which act more
or less continuously by pressing the organ downward.
These various influences, which are quite numerous and so
well understood that they need not be further detailed, may be
summed up under the term " internal traumata." As they
may vary considerably in different individuals, they offer a
ready explanation of the fact that different degrees of mobility
may be present in individuals of practically the same body-
form.
It may be well now to analyze our table of women as to the
etiological influence of other factors. Measurements were made
of 126 women. No attempt was made to select these cases,
except excessively fleshy women, in whom nothing within the
abdomen can be distinguished by palpation were excluded.
They were examined as the occasion presented itself, regardless
of whether symptoms were complained of or not.
Of the 126 women, 71, or a little over 56 per cent., were found
to have distinctly palpable or movable kidneys. Of the 7 1 cases, in
35, or 50 per cent., the left kidney was also palpable or movable,
but seldom to the same degree as the right. In only one case
was the left alone movable, and in this case, although the abdo-
men was very lax and easily palpable, no evidence of a right
kidney could anywhere be felt. Eighty-one of the cases were
married and 43 single; 2 not stated. Of the 81 married women,
41, or 50-f per cent., and of the 43 single women, 28, or 654-
470
HARRIS,
per cent., had movable kidneys. Concerning the number of
children born, the negative cases show that
6 had
o children.
4 "
I child
=
4
children
3 "
2 children
=
6
3 "
3
=
9
3 "
4
=
12
4 "
5
=
20
I "
8
=
8
I "
II
=
II
5 women had
=
70
or an average of 2.8 children to each woman. In 12 cases the
number of children was not known. Of the positive cases :
6 had
0 children.
2
I child
=
2
children
10
2 children
=
20
4
3
=
12
4
4
=
16
2
6
=
12
I
7
=
7
I "
10
=
10
30 w
fomen had
=
79
children
or an average of 2.6 children to each woman. In 12 cases the
number of children was not known.
These facts point to the conclusion that child-bearing does
not produce movable kidney and has no influence in that direc-
tion in the absence of the particular body-form. That repeated
pregnancies, by producing relaxation of the abdominal walls
and deterioration of the general health, may induce symptoms
or aggravate those already present is very probable, and will
be admitted. The same may be said concerning lacerations of
the perineum and displacements of the uterus. In three of the
negative cases complete procidentia was present. In one of
the positive cases there was complete procidentia, and in one
prolapsus, v/ith rectocele and vesicocele.
A most important question in this connection is the possi-
bility of producing a movable kidney by external violence, such
as a fall or a blow, or injury in the region of the kidney. The
MO VA BLE K I DN KY. 4/1
importance of this question from a medico-legal stand-point
makes it necessary to enter into it somewhat in detail. It is
usually stated in text-books, and it is a common belief, that
movable kidneys are frequently the result of an injury. This is
but another of the numerous post hoc propter hoc errors. An
individual falls or meets with an accident in which the body is
bruised or injured in some manner, and an examination some-
time thereafter reveals the presence of a movable kidney. It is
immediately concluded that the accident bears a causal relation
to the movable kidney, without stopping to consider whether
the movable kidney may not have been present long before the
accident, and in no manner influenced thereby. Several facts
have contributed in giving origin to this belief. First may be
mentioned the fact that the large majority of physicians are still
unfamiliar with the great frequency of movable kidney in women.
A physician of considerable experience recently stated it was a
very rare condition, and in all his experience he had seen but
four cases.
Secondly, in many cases movable kidney gives rise to no
appreciable symptoms, and in a large majority of those in whom
distinct symptoms are undoubtedly due to the movable kidney
the patients themselves are unaware of the cause of their symp-
toms, and often, unfortunately, the attending physician as well.
Thirdly, there is no means of determining how long a kidney
has been movable.
For the same reasons many writers on this subject have over-
estimated the causal influence of trauma. Most of the cases
recorded as due to trauma will not stand criticism. Sulzer,' in
regard to this relation, says : " However, one will have to be very
careful in judging of these very relations, for, on the one hand,
we know from other diseases how readily people in general refer
their troubles to a particular injury, and on the other hand, we
shall see later that upon the occasion of a fall or exertion, etc., a
movable kidney which is already present, may suddenly present
severe so-called strangulation symptoms, and thus become first
» Deufsch Zeits. f. Chir., 1891, Bd. xxxi., S. 506.
472 HARRIS,
known to the patient or physician after it has existed without
symptoms for months or years," After considering the anatomi-
cal fact of the looseness of the peritoneum covering a movable
kidney, he says : " The acute origin of a movable kidney, if it
occur at all, is then only possible when, owing to a congenital or
acquired looseness of the peritoneum, the disposition to the
trouble already exists." He further states: "The question
whether an acute traumatic origin of a movable kidney be pos-
sible may be very important in a medico-legal relation or in
insurance business, and I believe that without the acceptance of
a particular abnormal body condition, a movable kidney can
never be the immediate result of a trauma." Sulzer arrived at
these conclusions after a study of the cases in which a movable
kidney was supposed to have resulted from an accident, and
owing to the fact that the peritoneum which covers the kidney
in front and aids in holding it in place, is very much relaxed in
movable kidney, and this relaxation or pouching is so great that
it cannot be produced suddenly any more than a large hernial
sac can be produced suddenly. Keller^ is also of the opinion
that this condition cannot be produced suddenly, but requires a
considerable time for its development, and, therefore, a kidney
with a distinct range of motion discovered immediately or soon
after the receipt of an injury must have been movable before,
and its mobility cannot thus have been caused by the injury.
Concerning the traumatic origin of movable kidney, Biidin-
ger says :^ " When the kidney is fixed they (traumata) are
able to produce only the first step, while the formation of the
typical movable kidney requires still other conditions. A
sudden marked dislocation presupposes an extensive loosen-
ing of the kidney, and not onl)' that, but a space below the
kidney, with a considerable change in the relations of the
peritoneum."
Giiterbock^ concludes, from a study of injuries to the kidney,
" that a typical movable kidney does not occur as a result
1 Deutsch Chir., I.ief 67.
' Mittheil. aus d. Grenzgebiet, 1898-99, No. 4, S. 265. ' Quoted by Biidinger.
MOVABLE KIDNEY. 473
of trauma, but only a loosening of the organ, which later
may lead to mobilization unless the kidney becomes fixed by
adhesions. But even if one disregards the demand that a
traumatic movable kidney must show relations analogous to
the anatomical findings of the classical movable kidney, the
number of such cases is very small in which, in the living
subject, a connection between the injury and the mobility with
certainty can be demonstrated. The pain in a movable kidney,
which is discovered immediately after an accident, is not the
slightest proof of any connection between the accident and
the movable kidney, nor are all the other subjective symptoms
of any proof so long as it cannot be demonstrated with
unequivocal certainty that the kidney before that time was not
movable."
A simple fall is insufficient to give rise to a movable kidney
in the presence of normal relations. The injury must be severe
enough to produce a rupture or laceration of the tissues which
normally surround and fix the organ, in which case symptoms
sufficiently marked to direct attention to the nature of the
injury will always be present. The kinds of injuries most
liable to produce such lacerations are:
1. Severe falls upon the buttocks in a sitting position.
2. The body is thrown violently against some object, striking
the region of the kidney so as to forcibly adduct the lower or
loose ribs. The same effect is produced if the object be
movable and the body stationary.
3. This region of the body is compressed between two oppos-
ing forces. Such injuries may produce lacerations of the peri-
renal adipose tissue, with the formation of a perirenal haematoma,
which may vary much in size. These haematomata are retro-
peritoneal, and it is the exception when the peritoneum is torn.
Symptoms of sufficient severity to direct immediate attention
to the region of the kidney are always present in case of
laceration with the formation of a hnsmatoma of any material
size. The swelling produced by the h;tmatoma may also be
usually felt on palpation, although the tenderness may be
so severe as to interfere in this direction. Accompanying
474 HARRIS,
the absorption of such a haematoma an increased amount
of connective tissue usually forms in the adipose capsule,
which may fix the kidney more firmly than before. On the
other hand, the haematoma may dissect up the perirenal fat, or
lead to the formation of a perirenal serous cyst, in the loose
space of which the kidney may move about, and thus an injury
may be the direct cause of a movable kidney.
The symptoms which immediately follow the injury will
direct attention to this possibility, but such cases are rare. Of
course, an injury may produce a laceration of the kidney proper
without the formation of a perirenal haematoma, or the two
conditions may exist. When the kidney substance is lacerated,
or the pelvis opened, the presence of h^ematuria will direct
attention to the fact.
It should be remembered that in the presence of a movable
kidney a slight injury, such as a fall, or jarring of the body, or
straining at lifting, may produce a slight haematuria for a few
days, without the occurrence of a material lesion in the kidney,
and without other symptoms particularly referable to this
organ. In fact, this is so common that the presence of such a
haematuria following a slight injury should at once suggest the
possibility of a movable kidney, and lead to an examination
with this point in view. The more often such examinations
are made immediately following such injuries, the less often it
will be found that the injury had aught to do with causing the
movable kidney.
The fact that a movable kidney is surrounded by a loose peri-
toneal and connective tissue pouch, which must necessarily be of
slow formation, precludes the possibility of a movable kidney
being produced suddenly by an injury. It is in just this class
of cases that the value of correctly estimating the body-form
by the measurements as herein mentioned is so apparent. Thus
if a woman with an unmistakable body-form of the positive
type present herself with a movable kidney which is said to
have followed an injury, it may with practical certainty be
asserted that the movable kidney is the result of the body-form,
and arose independently of the injury. The injury but calls
MOVABLE KIDNEY. 475
attention to a condition already present, but perhaps unrecog-
nized. Of course, it is not denied that a movable kidney may
be aggravated by an injury, or that such a kidney may be
injured by external violence as well as a kidney that is fixed
Of the cases comprising the table there were two belonging
to the negative tj'pe in which a history of an accident, such as
might have injured a kidney, was present, but in none of these
could the kidney be felt.
Of the positive cases, 7 gave the history of a fall or other
injury. One, No. 70, was not aware that she had a movable
kidney, but gave a history of unmistakable symptoms referable
to the urinary organs and stomach which antedated the injury,
thus clearly eliminating the injury as a causal factor in the
movable kidney.
In Case No. 1 10 the injury, a jarring of the back, was claimed
as the cause of the movable kidney. She was examined within
a month after the injury, when the kidney was found so freely
movable and so devoid of tenderness, and the injury was so
slight, as to preclude the possibility of a causal connection.
Case No. 42 had a fall, injuring the knee, but the region of
the kidney was not involved, and the presence of the movable
kidney not suspected.
In Case No. 59 the injury was undoubtedly instrumental in
producing the mobility of the left kidney. The right kidney
was also very movable, but this was an old condition. Follow-
ing a rather severe injury to the left side, in which the left
tenth rib was fractured, there developed a large swelling,
haematoma, about the left kidney, which was very painful, was
accompanied by haematuria, and confined the patient to bed
for several weeks. The swelling was several months in dis-
appearing, and a year after the accident the kidney was still
somewhat enlarged, tender, and movable. In this case there
was • no question as to the injury to the kidney and its
surroundings.
In Case No. 37 it was first thought that the injury bore a
causal relation to the movable kidney. A chair was removed
from behind the patient as she was about to sit down. She sat
476 HARRIS,
down on the floor very heavily. Considerable pain and tender-
ness in the right side with light fever followed for some time.
The tenderness was so limited to the region of the caecum that
chronic appendicitis was diagnosed. Some two months later
the appendix was removed. It was not found to be directly
involved, but recent adhesions were found between the caecum
and ascending colon and the abdominal wall. Six months later
the patient returned, still complaining of pain in the back and
right side. The freely movable kidney was now recognized and
nephrorrhaphy performed, with relief from the symptoms. It
seems more probable, after reviewing this case, with the knowl-
edge furnished by the two operations, that the kidney was mov-
able at the time of the fall, and that the sudden motion given
to it by the fall produced the mild traumatic peritonitis about
the caicum and colon which produced the symptoms. At the
operation on the kidney there were no evidences found of an
old haematoma, nor of unusual formation of connective tissue.
In Case No. 1 14 the injury, a fall from a tree, occurred twenty
years ago, and the history was too indefinite and remote to be
considered at this date.
Case No. 35 was a poor, hard-working woman, with a pen-
dulous abdomen and marked visceral ptosis. A year and a half
before, she fell on her side and hips on the street. Both kid-
neys were movable to the second degree, and it was claimed
that the fall was responsible for this condition. The fall, how-
ever, was not a severe one ; no complaint was made at the time
of any trouble in the region of the kidneys; the pendulous
abdomen and visceral ptosis were present for a long time before
the fall. It is more than probable, therefore, that the kidneys
were movable at the time of the fall, and that the injury had no
effect whatever on them. Thus of the 7 cases in only i had
the injury any causal relation to the movable kidney, and in this
case a material lesion in the shape of a large perirenal h;uma-
toma was present, which was distinctly recognized at the time
and which produced severe symptoms, confining the patient for
several weeks to bed.
Based upon these facts it may be concluded that the popular
MOVABLE KIDNEY. 47/
belief in the traumatic origin of movable kidney is not sup-
ported by the evidence, and that it is highly improbable that a
single injury, such as a fall, which does not produce a material
lesion of the perirenal tissues, recognizable by well-defined
symptoms, is ever the immediate cause of a movable kidney.
It would be of considerable interest to know at what age or
period of life the body-form becomes established, and how soon
it influences the location of the kidney. I have not sufficient
data at present upon which to base an opinion on this point,
and it can only be determined after a systematic examination of
a large number of individuals during the developmental period.
The measurements of a number of children are contained in
the table, but the number is too small to permit of an analysis.
It is evident, however, that in early childhood there is no mate-
rial difference in the body-form of the two sexes. The number
of men upon whom measurements have been made is also too
small to establish normal averages, and as there was but one
case of movable kidney in the number no differences can be
drawn between the negative and positive cases. The measure-
ments taken, however, show that the lower zone is much smaller
than in women, while the middle and upper zones are larger.
The increased size of the middle zone is particularly suggestive,
inasmuch as movable kidney is so rare in men compared with
women. The tendency is to a low Index, No. i, and a high
Index, No. 2, which is characteristic of the negative body-form.
The man in whom the movable kidney was found had had two
or three severe falls of several feet, one of which was followed
by haematuria and distinct evidences of a lesion of the kidney.
Stiller has somewhat recently called attention to the associa-
tion of a loose or floating tenth rib and movable kidney. He
claimed the association was so constant as to establish a rela-
tion between the two, and a floating tenth rib was therefore
called the "Stiller stigma," or the Stiller sign of a movable
kidney.
The condition of the tenth rib was noted in 1 10 of my cases,
49 of which were negative and 61 positive. Of the negative
cases the tenth rib was found loose in 26 and fixed in 23. In
4/8 HAKRI3,
the positive it was loose in 38, fixed in 22, and in i case both the
ninth and tenth were loose. By the term "loose" is not neces-
sarily meant absolutely free and floating, as are the eleventh and
twelfth ribs, as this condition is not common, but in case the at-
tachment of the rib to the costal arch was so slight as to permit
considerable free motion independent of the costal arch it was
said to be " loose." In case the attachment was so firm as to pre-
vent any material independent motion it was said to be " fixed."
From my examinations, therefore, Stiller's observations can-
not be confirmed. While a loose tenth rib is the rule in women,
it bears no definite relation to the presence or absence of a
movable kidney.
The contraction of the middle zone explains the great fre-
quency with which the so called vertical stomach is associated
with movable kidney, as the pylorus and upper duodenum de-
scend more or less with the kidney, while the cardia remains
fixed by the oesophagus.
It is not the intention to discuss the clinical aspect of mov-
able kidney, hence the symptomatology, diagnosis, etc., will be
passed without further remarks.
Concerning the treatment, attention will be briefly directed
only to the method of operating, but it is not to be understood
by this that it is necessary to operate all cases, as such is far
from being the case. However, when it is decided that the
symptoms with which a patient suffers are due to the movable
kidney, there is little reason to hope for permanent relief by any
other method than that of operative fixation of the organ. The
tendency in recent times has been to fix the kidney too high up,
apparently from the idea that the disturbances were due rather
to the fact that the kidney was too low than that it was too
freely movable. If the points brought out in this contribution
are correct, the descent of the kidney has been brought about
by the fact that the middle zone of the body cavity, in which
the major portion of this organ normally should lie, is too small
to contain it. It would, therefore, appear unreasonable to at-
tempt to fix the kidney in a cavity too small for it and from
which it had been ejected.
MOVABLE KIDNEY. 479
Should this be done, however, the same factors which caused
the kidney to become movable in the first place are again
brought into action, with the probabilities of a recurrence. Or
should the kidney be so firmly fixed in a high position that it
cannot again be displaced, symptoms even more severe than
those for which the operation was undertaken may result. The
author has recently seen two such cases operated by most excel-
lent surgeons, one in Chicago and the other in New York, with
perfect operative result. The kidneys were high and firmly
fixed, yet both cases suffered infinitely more after the operation
than they did before, and in one case the suffering became so
intense that about two years after the first operation relief was
obtained by removing the kidney entirely.
The principle, then, that should guide us in fixing a movable
kidney is to take into consideration the body-form and fix the
organ in a location where it will not again .be subjected to the
same influences which caused its descent. This means that the
kidney should not be crowded up to the highest point, but fixed
lower down in an easy position, and so the ureter will escape
at the most dependent part. If this be done the chief cause
of relapse will be removed. The method of operating is as
follows :
A muscle-splitting incision is made, beginning a little in front
of the tip of the twelfth rib and extending downward, forward,
and inward in the line of the fibres of the external oblique
muscle. These are separated bluntly, and then the fibres of the
internal oblique and transversalis, which cross the line of incision
at almost a right angle, are separated in the same manner.
The peritoneum is carried inward and the perirenal space en-
tered. All the perirenal fat is removed, but the perirenal fascia
is carefully preserved. The upper portion of the ureter should
be examined to see that it is not fixed, and thus become flexed
or kinked by moving the kidney. The perirenal fascia with the
peritoneum covering in, and to which it is usually quite firmly
attached throughout its anterior and inner portions, forms the
pouch or sac in which the kidney moves. This space, bounded
by the perirenal and retrorenal fasciae, sometimes called Gerotta's
480 HARRIS,
space, is somewhat triangular in shape, with its apex extending
downward toward the brim of the pelvis.
The object of the operation now is to so close this space and
contract the pouch or sac that the kidney will no longer have a
free space in which to move. This is accomplished by closing
this space from before backward with catgut sutures. The colon
lies just anterior to this space, and should not be injured. Should
the pouch in which the kidney moves be very large and bulge
the peritoneum to the inner side of the colon, a small opening
may be made into the peritoneal cavity just to the outer side of
the colon, and the sutures passed through the mesocolon from
within, thus approximating this layer to the posterior abdominal
wall and obliterating or diminishing the pouch. By passing the
sutures in this manner the danger of including in them the colica
dextra or sinistra artery, as the case may be, is avoided. The
branches of the lumbar plexus of nerves on the posterior wall
should also be remembered, and care taken not to include them
in the sutures.
The effect of suturing in this manner is to obliterate the space
in which the kidney has been moving up and down. The outer
edge of the perirenal fascia is then sutured to the lumber fascia,
posterior to the line of incision through the walls. By drawing
more on the upper or lower portion of the fascia the kidney may be
rotated on its antero-posterior axis, as may be necessary in order
to bring the ureter at a proper dependent position. When the
operation is finished the kidney will be found firmly held in
position, yet not so fixed that it cannot move up and down
slightly, as a normal kidney should during respiration. All
abnormal excursions of the kidney, however, are completely
arrested, although the organ occupies a lower position than
normal. No stitches involve the kidney substance. This oper-
ation was not of sudden birth, but of gradual development dur-
ing the past three or four years. Clinically the results have
been good, and in patients examined as long as two years after
the operation the kidney has been found still in the location in
which it was fixed and without any increase in its range of
motion. In closing, the following conclusions are presented :
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MOVABLE K I DNEY. 48 I
1. The essential cause of movable kidney lies in a particular
body-form.
2. The chief characteristics of this body-form are a marked
contraction of the lower end of the middle zone of the body
with a diminution in the capacity of this portion of the body
cavity.
3. This diminution in the capacity of the middle zone de-
presses the kidney so that the constricted outlet of the zone
comes above the centre of the organ, and all acts, such as
coughing, straining, lifting, flexions of the body, etc., which
tend to adduct the lower ribs, press on the upper pole of the
kidney and crowd it still further downward.
4. It is the long-continued repetition, in a suitable body-form,
of these influences, which collectively may be called internal
traumata, that gradually produces a movable kidney.
5. A distinctly movable kidney is never the immediate result
of a single injury or external trauma.
Am Surg
PNEUMOTOMY FOR ABSCESS OF THE LUNG.
With Exhibition of Patient.
By W. JOSEPH HEARN, M.D.
AND
W. J. ROE, M.D.,
PHILADELPHIA.
The surgical treatment of abscess of the lung by pneu-
motomy is not a modern idea. Many cases are recorded in
literature on the subject of intentional, incidental, or accidental
incisions and drainage of lung abcesses, with varied results.
For several centuries surgeons have recognized the necessity of
and expressed themselves in favor of such a procedure, but not
until the latter part of the last century was pneumotomy generally
practised. Among many others, such men as M. Reclus, True,
Paget, Tuffier, Keen, A. Pearce Gould, Le Conte, Terrier, Carl
Beck, Sonnenberg, Matas, Parham, and Murphy have done much,
both by their work and writings, to advance this department of
surgery.
The advent of the Rontgen rays has greatly enhanced its
possibilities by assisting to definitely locate the abscess. The
case in point demonstrates this very clearly, as the first two
operations were performed previously to the employment of the
rays. Again, the employment of artificial respiration, by means
of the apparatus devised by Fell and O'Dwyer, or that of Bloom,
has been practically demonstrated by Parham, Keen and others,
and has given this form of surgery new impetus by lessening
the dangers of an incident pneumothorax.
Pneumotomy has a wide field of use, but is especially indi-
cated in the following conditions : {a) In abscesses, such as
PNEUMOTOMY FOK ABSCESS OF THE LUNG. 483
a single abscess; [d) saccular bronchiectatic abscess ; (c) a single
tuberculous abscess, with retention of secretion, high fever, and
localized tuberculous involvement of the lung tissue; {d) in
localized abscesses from the entrance of foreign bodies into the
bronchi, gunshot and penetrating wounds of the lung.
The time being limited and the history of the case necessarily
long, we have endeavored to incorporate only the practical points
of direct bearing.
S. L. H.,male; born in England in 1875; salesman by occupation.
His parents are in good health ; also five brothers and four sisters, and
there is no tubercular history in his ancestry. His grandparents died
of senility.
The present trouble began when patient was between three and four
years of age. Other than this he has not had any serious illness. He
was always well until during the autumn of his. fourth year, when his
clothing became saturated from a fall into a river, and was not removed
for several hours, the patient remaining out in the cold and becoming
thoroughly chilled.
Following this, he was very ill for one month with fever, cough, and
pain in the right half of the chest, at the end of which time he began
to cough up large quantities of purulent material, and about the end
of each coughing attack the material would be quite bloody, and some-
times almost pure blood.
He improved during the following two months, at the end of which
time he was very much better, but continued to cough up considerable
purulent material, and subsequently in smaller amounts, and there was
present a constant offensive exhalation.
He was taken to Germany for treatment, where he remained for
some months, and was treated medicinally, and pronounced incurable.
He was also treated at the same time by means of braces for genu varum.
One year after the onset of his illness his parents removed with
him to New York, having been first advised by physicians that his
condition was such that he would probably not survive the voyage.
They arrived in New York City in September, 1880, and two weeks
later his cough become more troublesome, accompanied by fever and
pain in the right side of the chest, but his appetite remained good.
He was admitted to the Jewish Hospital, where he remained for nine
months.
484 HEARN AND ROE,
Diagnosis unknown.
After residing for about one year in New York City he removed to
Richmond, Va., where he resided for twelve years, and during that
time he had more or less cough, with expectoration of considerable
pus, and a constant offensive odor to his breath, and did not at any
time feel entirely well.
After a subsequent very brief residence in Philadelphia he returned
to Richmond, and spent seven months in the Retreat for the Sick,
without receiving any benefit ; but was told by Dr. Levy that an oper-
ation was required to effect a cure.
He again removed to Philadelphia in December, 1895, and was
soon afterward admitted to the Jefferson Hospital during the service
of Dr. W. W. Keen. On admission the following notes were taken :
Temperature, 98^°; pulse, 92 — full and soft ; respiration, 24; cough
occurs in paroxysms, and with it the expectoration of large quantities
of purulent, horribly fetid material ; violent coughing has been fol-
lowed by blood-spitting; complains of dyspnoea, even so severe as to
necessitate sitting posture ; has evening chilliness and rather profuse
night-sweats; complains of weakness, and has lost 25 pounds; pain
varying in severity through right lung ; sputum amounts to four ounces
twice daily.
On December 19, 1895, he was operated on by Dr. W. W. Keen,
assisted by the writers. For these notes, as well as those of the second
operation, we are indebted to the courtesy of Dr. Keen.
A curved incision downward was made along the line of the nipple,
exposing the fifth intercostal space, which was incised, and, believing
the pleura to be adherent, the largest needle of an aspirator was intro-
duced into the lung to a depth of nine centimetres, along which a pair
of forceps were introduced and separated about one and a half inches,
and were drawn out, after which a rubber drainage-tube was inserted.
Eight days later Dr. Keen explored further, breaking through the wall
of the sinus, which had formed, with a curved haemostatic forceps in
three different directions — upward and inward, and again on the fol-
lowing day in two directions.
Twelve days after the operation the patient was etherized, and Dr.
Keen explored carefully with his finger in different directions, and
finding considerable resistance at one point he explored with a curved
sound, and introduced a No. 30 catheter and fastened it in place with
a stitch. These explorations were unsuccessful in finding the abscess
or its tract.
PNEUMOTOMY FOR ABSCESS OF THE LUNG. 485
He was readmitted to the Jefferson Hospital in November, 1896,
during the service of Dr. W. W. Keen, and the following notes of
physical examination were made :
AuscuUation of Right Half of Chest. Absence of vesicular murmur
below the line of the spinous process of the eighth dorsal vertebra and
the cartilage of the seventh rib in front, with frequent loud gurgling
heard below this line, and especially posterior. Above this line the
•vesicular murmur is impaired and harsh, with crepitant and subcrepi-
tant rales; but the murmur soon becomes normal toward apex of chest.
Vocal resonance is much decreased below and increased just above the
line for a very limited area. Above this it is normal. Left lung is
normal.
Percussion of Right Half of Chest. Gives good resonance until
approaching the line, when the sound is rapidly changed and becomes
dull, and a little below becomes flat, which flatness is continuous with
that of the liver. There is more tenderness on right side. Vocal
fremitus is lost below the line, but about the ssime above as upon the
opposite side of the chest. The daily quantity of pus coughed up
amounted to about one pint, which was examined by Dr. Harris, who
found, beside the ordinary composition of pus, the bacillus fetidus,
but no tubercle bacilli, lung tissue, or elastic fibre. Urine examination
negative.
Second operation on November 2.9, 1896, by Dr. W. W. Keen,
assisted by the writers. .
An aspirating needle was introduced posteriorly in the eighth inter-
space, and apparently some pus escaped. With the needle in position
two inches of the eighth and ninth ribs were resected. The pleural
surfaces were found adherent, and were incised, and the lung tissue
was penetrated with the finger to a depth of three inches, following
the direction of the needle; then in a downward direction to opposite
the eleventh interspace, and also in an upward direction to a corre-
sponding extent ; then with the finger the pleural surfaces were sepa-
rated in a downward direction to the level of the diaphragm, after
which a large rubber drainage-tube was inserted.
Decetnber 7, 1896. Dr. Keen introduced through the drainage-
tube a sound in three directions into the upper portion of lung to a
distance of six and a half inches without finding any cavity.
\oth. Drainage-tube removed and was found to be five and a half
inches into lung, including chest wall. These explorations were also
unsuccessful in finding the abscess or its tract.
486 HEARN AND ROE,
Patient was readmitted to the hospital on December 19, 1898, dur-
ing the service of Dr. W. Joseph Hearn. Since he left the hospital in
December, 1896, his condition had practically remained unchanged.
He has had daily from six to eight paroxysms of coughing, with expec-
toration of exceedingly offensive pus, but no blood.
A specimen of the sputum and pus coughed up was examined by Dr.
J. D. Robinson, pathological resident, as follows:
Specimen stained by ordinary method, also for tubercle bacilli.
Histological examination shows numerous pus and a few epithelial cells
and granular debris. Bacteriological examination shows numerous
bacilli, a few micrococci, and a few streptococci. Tubercle bacilli
not found. Urine examination negative.
His deplorable condition was such that we had to isolate him. By
allowing the pus to accumulate in the cavity until filled we were
able to demonstrate with the fluoroscope that it was in or about the
base of the lung. A skiagraph was also taken with the abscesses only
partially filled, as the patient could not retain the pus in a recumbent
position.
Having assisted Dr. Keen in his most careful and thorough explora-
tions of almost the entire lung, we decided that if the abscess was in
the lung, it was in or about the central portion of the base, or else was
a case of encysted empyema between the base of the lung and the dia-
phragm, or the inner surface and the pericardium, or possibly a sub-
diaphragmatic abscess with pulmonary sinus.
Against the diagnosis of encysted empyema was the presence of the
offensive odor, in contrast to the case reported by D. S. Fairchiid, in
which there was no odor to the pus. Loud gurgling rales could be
heard, and the patient felt a decided pressure, which frequently caused
him to vomit soon after eating. This pressure was in the region of
the base of the lung and diaphragm when the abscess became filled.
Ether was administered. A curved incision was made over the sixth
rib in the mammiliary line, and two inches of the osseous extremity of
the rib resected. The parietal pleura was opened and the visceral
pleura was found adherent, but could easily be separated. With
the fingers the pleural surfaces were separated between the base
of the lung and the diaphragm and between the lung and the
pericardium as far as the fingers would reach, both backward and
upward ; but no evidence of pus was found and no dense adhe-
sions. At the same time the lung was carefully palpated (Tuffier's
method of locating an abscess, and preferred by Sonnenberg), but
PNEUMOTOMY FOR ABSCESS OF THE LUNG. 487
nothing specially abnormal was indicated. While exploring backward
between the base of the lung and the diaphragm a decided resistance
was encountered. Instead of the fingers passing backward and down-
ward over the dome of the diaphragm they met with this resistance,
which carried them upward and backward against the lung, showing
the pleural surfaces to be firmly adherent.
By catching the visceral surface at this point between the fingers it
was found to be elastic, and could be drawn sufficiently forward to be
readily observed in the wound, and also gave the sensation of being
part of a wall of an empty cavity. Believing that this was the abscess
wall, we decided to make a posterior incision, which would enable us
to employ direct drainage. We therefore made a curved incision just
beneath the angle of the scapula, and exposing the ninth rib, resected
two inches of it.'
The pleural surfaces were evidently adherent, thickened, of a gray
appearance, and gave the sensation of composing the abscess wall, and
following the rule laid down by Sonnenberg : f'lf the pulmonary tis-
sues are hard, divide them with a knife, as there is no danger of hem-
orrhage ; if the pulmonary tissues are soft, divide them with the cautery,
as there is great danger of hemorrhage." On incising this in the
direction of the ribs we opened directly into the abscess cavity, and
several drachms of pus escaped. The walls of the abscess cavity were
everywhere soft and elastic, and felt smooth on the interior, and, with
two fingers in the abscess cavity, they could be carried their full
length in every direction without meeting with any special resistance.
At the upper and inner portion of the cavity could be felt two open-
ings, apparently of bronchi. A long probe was then passed into one
of these openings, and was readily carried up through the bronchus
into the trachea, which was repeated several times, and at each pro-
duced a severe paroxysm of coughing, the patient not being entirely
anaesthetized. As the patient coughed, mucus, pus, and blood were
expelled through the wound.
Two large rubber drainage-tubes were introduced into the abscess,
and the cavity was distended by iodoform gauze packing, A small
rubber drainage-tube was put in the anterior wound.
We quote subsequent notes by Dr. A. N. Mahon, resident physician :
"December 21, 1898. Patient reacted well from ether ; wound dressed.
* It is interesting to note that Carl Beck says that old cavities can be best reached hy
an incision at the angle of the scapula.
488 HEARN AND ROE,
looking well ; no pus from anterior tube ; a considerable amount from
posterior tubes ; there has been no expectoration of pus.
" 22d. Pus is coming freely from both anterior and posterior tubes.
" 2<^th. Part of stitches removed ; pus still coming freely from both
wounds; tubes shortened on 25th and 27th. There has been no ex-
pectoration of pus except on the 23d, when it was very slight — about
one drachm ; patient sitting up.
" 3IJ'/. Balance of stitches removed ; patient walking around.
"/anuaryi, 1899. Discharged in good condition; drainage-tubes
still in place, having been shortened ; pus draining freely ; wounds
looking well ; no expectoration."
The suppuration in the anterior wound was clearly due to secondary
infection, and soon ceased, the wound healing completely in sixteen
days. The pyothorax in this case did not delay convalescence. One
of the posterior tubes was dispensed with in three weeks.
The abscess cavity was irrigated daily in the Out-patient Depart-
ment for the following year and a half, after which the patient went
South, and kept up the irrigation himself.
During this time the local effect upon the abscess wall of many
fluids by irrigation was noted, the principal of which are the following:
Plain sterile water ; normal salt solution ; boric acid saturated solu-
tion ; hydrogen dioxide in 5 to 15-volume solutions; listerine diluted;
carbolic acid, i to 3 per cent, solution ; potassium permanganate, i
to 30,000 to I to 1000 ; pyoktanin, i to 30,000 to i to 1000; forma-
lin, half of I per cent. ; distillate of moss, prepared by John John-
son ; palladium bichloride, i to 5500.
The most appreciable benefit derived from irrigation by any or all
was the cleansing. None had any influence in lessening the size of
the cavity, but some were instrumental in considerably lessening the
quantity of pus formed.
The bichloride of palladium solution evidently did more to lessen
the quantity of pus than any other, and also prevented or relieved
dermatitis or excoriation of the skin surfaces, which frequently occurred
from the irritation caused by purulent discharge while using other irri-
gants. Further, it did not cause any unpleasant eff"ects, even if allowed
to be coughed up daily.
The permanganate, pyoktanin, and formalin solutions usually excited
a dry cough, and they could only be used for a few days in succession.
The colored fluids were used also as a diagnostic means ; with the
patient lying upon his left side the abscess cavity could be filled, and
PNEUMOTOMY FOR ABSCESS OF THE LUNG. 489
then, by holding a compress over the drainage-tube, the patient would
cough up, and all of the pus and mucus would be equally stained by
the solution. This to a certain extent demonstrated that there was
no other large pus cavity in the chest, for if such were the case the
contained pus could scarcely become so thoroughly stained by being
mixed with the pus from the injected cavity, or by coming in contact
with the stained walls of the respiratory tract while being expelled.
During these two years he was never compelled to expel the con-
tents of the abscess cavity through the respiratory tract, except when
the drainage-tube (although quite large) became occluded by thick
mucus or the dressing became saturated.
His general health was vastly improved. Gained in weight and
strength, and seldom felt bad. Previous to draining the cavity he
had occasional severe chills, followed by fever, but during this time
he was free from such. The horribly offensive odor was very greatly
lessened, and life was much more pleasant, except for the annoy-
ance of the daily irrigation and the necessity for frequent change of
dressings. For these reasons he made an earnest appeal for further
relief.
We decided to made another attempt to relieve his condition, hoping
that we could completely excise the abscess cavity, or, if we found
this not expedient, we could excise a portion of the cavity and suture
the remainder to the surface of the skin, converting it into an open
cavity — a plan suggested by Dr. J. Chalmers Da Costa.
He was readmitted to the hospital on December 14, 1900, and we
operated on the i8th. Again, as in all the previous operations, ether
was administered. A tri-flap or Y-incision was made down to but not
into the sinus, exposing a portion of the eighth and ninth ribs, which,
having been re-formed, were again resected three and four inches
respectively. The middle of the resected portion of the ninth rib
contained a large fenestra, occupied by the sinus. The sinus and a
portion of the abscess wall were dissected free from the surrounding
pleura and lung tissue to a depth of about one and a half inches.
Some bleeding was taking place from the lung tissue, and on account
of the extent of the abscess cavity, we decided to excise by circular
incision the portion of wall which we had dissected free, after which
we sutured the circular margin of the abscess cavity to the margin
of the skin flap. Our triangular flap, which we had designed for
this purpose, worked admirably, allowing a continuous and regular
approximation.
490 HEARN AND ROE,
The cavity was packed with iodoform gauze, and the patient, as in
all the previous operations, convalesced rapidly, and was up and
around in ten days. One month after operation we took the follow-
ing measurements of the cavity and had this delineation made :
The cavity extends obliquely upward, inward, and forward. There
is no longer any retention of secretion within the cavity, the capacity
of which constantly alternates with respiration. On deep or forced
expiration the walls of the cavity approximate. At the apex of the
cavity, where the bronchi enter, a polypus extends into the cavity about
2 cm. and 8^ cm. from the surface. There is a narrow septum divid-
ing the apical portion ^}4 cm. from the surface. The depth of the
upper surface of the cavity is 7 cm. and lower 95^ cm. Its diameter
in vertical is 5 cm. and lateral 3 cm. The walls of this cavity are
quite elastic and will admit of very considerable distention, and this
readily accounts for the large quantities of pus (four to six ounces)
expelled at frequent intervals previous to drainage.
A specimen of the excised wall of the cavity was examined in the
laboratory of the Jefferson Medical College Hospital by Dr. John
Funk.
Upon microscopical examination the inner surface of the wall of
the cavity is lined with translucent material, which did not stain by
Weigert's method, nor did it take any other basic or acid stain. The
remainder of the wall was apparently composed of numerous laminae
of a dense homogeneous substance. The sections stain with h^ema-
toxylin and eosin; toluidin blue and eosin retain the basic stain. Sec-
tion stained by Weigert's fibrin stain retains the stain throughout the
section, with the exception of the translucent substance referred to
above. The translucent material is undoubtedly degenerated debris,
and the wall of the cavity is composed of laminae of fibrin.
He was benefited by the last operation as follows : The offensive
odor is practically entirely gone ; he is relieved of the necessity of
having the cavity irrigated and the annoyance of wearing a drainage-
tube. He complains, however, of the annoyance of wearing and fre-
quently changing the dressings, and that each day he is compelled to
cough up small quantities of mucopurulent material, which evidently
comes from other portions of the bronchial tract, and, although he is
vastly improved in many respects, and his general health (which pre-
viously was very poor) is now good, and the horribly offensive odor,
which practically compelled him to live a recluse, is gone, he is not
cured.
P N E U M O T O M Y FOR ABSCESS OF THE LUNG. 49 I
He desires to have the abscess obliterated and the opening in the
chest closed, and also, if possible, to be relieved of the present muco-
purulent expectoration.
The following questions arise : What were the etiological
factors in this case? i. Is this an abscess of the lung follow-
ing gangrene? 2. Is this a saccular bronchiectatic cavity?
3. What is his present condition, and what can be done to
relieve or cure it ?
The exposure to cold, followed by an acute illness (probably
pneumonia), and immediate subsequent expectoration of large
quantities of pus and blood, with a history of continuous ill
health, associated with expulsion of quantities of purulent mate-
rial and the finding of one large cavity, lead us to believe that
this was an abscess following localized gangrene of the lung
in contradistinction to saccular bronchiectatic cavities, which
would develop gradually and probably never attain such size.
Had the sputum been examined early in the case elastic fibre
and lung tissue would probably have been found. The long
duration of the cavity had rendered it smooth on its interior
and formed a thick fibro-elastic wall, with little or no surround-
ing induration.
Although we believe that there is only this one abscess
cavity, yet his present condition strongly suggests secondary
bronchiectasis. How much this condition is the result of the
cough or of the associated cirrhosis of the lung, which evi-
dently is present, especially in the lower lobe, we can only
surmise.
As to his further treatment : at the time of last operation we
decided to subsequently obliterate the cavity by promoting
adhesions through the use of the cautery, but later evidence of
the probable existence of some degree of bronchiectasis altered
our decision.-
If we obliterate this cavity by causing adhesion between the
surfaces we would only increase the bronchiectatic condition by
increasing the traction of the cirrhotic lung tissue. Therefore,
we believe that to cure this condition it is necessary to remove
the greater portion of the lower ribs, with their periosteum,
492 HEARN AND ROE,
allowing the chest wall to fall in, and by this means obliterate
not only the original cavity, but the bronchiectatic cavities as
well.
This plan was suggested by Dr. Oscar H. AUis in 1891 for
the cure of tuberculous cavities ; but so far as we know it h£^s
never been suggested for bronchiectasis, and if the members of
this Association have no better suggestion to make, we will
resort to this procedure.
In reviewing the case there are certain facts evident : The
localization of a cavity in the lungs, which collapses when
empty, having soft, tough, elastic walls, is most difficult. Few
patients can stand this operation without a general anaesthetic,
and, when given, the contents of the abscess will certainly be
expelled; and, even though an abscess wall of this character
should be reached by an aspirating needle, it would be carried
in front of the needle and rarely penetrated. If the operation
could be performed under local anaesthesia this difficulty would
be largely overcome, as the abscess wall would offer greater
resistance, and if palpation were employed the resistance would
again be encountered.
In this case there was no difficulty experienced from the
administration of ether, notwithstanding the warning of Carl
Beck to the contrary, that ether should never be given, and for
a general anaesthetic chloroform only should be used.
Again, the cavity was freely irrigated from the day of oper-
ation, and no difficulty was encountered, even though the
bronchus became flooded and the patient was compelled to
cough. Another point demonstrated in his case is that, even
though two large drainage-tubes were inserted, when the
abscess cavity was first opened, and although the cavity freely
communicated with the bronchus, there M^as neither then nor
subsequently any impairment of respiration. On the contrary,
Sonnenberg advises tamponing the abscess cavity of the lung,
which communicates with the bronchus, in order to prevent
embarrassment of respiration. When, however, the patient
was compelled to cough, he experienced difficulty unless a
compress was held over the wound and tube.
PNEUMOTOMY FOR ABSCESS OF THE LUNG. 493
BlISLIOGRAPHY.
AUis, Oscar H. Transactions of the Pennsylvania State Medical Society, 1891.
Beck, Carl. Journal of the American Medical Association, October 2, 1897.
Fairchild, D. S. Ibid., September 30, 1898.
Gould, A. Pearce. Practitioner, February, 1900.
Keen, W. W. Proceedings of the American Surgical Association, 1901.
Le Conte. Philadelphia Medical Journal, April 14, 1900.
Matas. Annals of Surgery, April, 1899.
Murphy. Journal of the American Medical Association, July 23, 30, and August 6,
1898.
Paget. Surgery of the Chest, 1896.
Parham. Monograph, 1899: Thoracic Resection for Tumors Growing from the
Bony Wall of the Chest.
Reclus. Paget : Surgery of the Chest, Appendix A.
Sonnenberg. Wiener medicinische Blatter, 1897, No. 40.
Terrier. Annales de la Societe Beige de Chirurgie, June, 1900.
True. Chirurgie du Poumon, 1885.
Tuffier. Medicine, December, 1897.
EXCISION OF A PART OF THREE RIBS AND A
PORTION OF THE DIAPHRAGM
FOR SARCOMA.
By C. B. porter, M.D.,
BOSTON, MASS.
This case is reported as a contribution to the surgery of the
chest.
The patient, H. J. D., male, aged forty-one years, born in Boston,
entered the Massachusetts General Hospital on January i6, 1900.
Occupation, pressman.
The previous and family history is of no importance.
The present illness began about three and one-half months ago.
At that time he felt a stitch-like pain in the right side, localized in the
anterior axillary line at the level of the eighth rib. The pain was
increased on deep inspiration and became especially severe when
physical activity caused increased respiratory movements.
Three weeks later the patient first noticed a swelling at the seat of
the pain. The tumor was hard at first, but became softer as it
increased in size. At no time has the growth been tender to ordi-
nary pressure.
Coincident with the growth the patient has been losing strength
and weight. During the past three months he has lost eighteen
pounds.
Physical Examination. Well-developed and nourished man : heart
and lungs negative.
On the right thoracic wall is a dome-shaped tumor, the size of one-
half a medium-sized cocoanut. The centre of the tumor is at the
level of the eighth rib in the anterior axillary line. The tumor moves
with respiration. (Figs. 1 and 2.)
The growth is not adherent to the skin, but is firmly attached to the
EXCISION OF RIBS AND OlAPHKAGM FOR SARCOMA. 495
ribs. It is soft on palpation, suggesting semi-fluid contents. On deep
pressure the tumor is tender. The chest was examined by Dr. F. C.
Shattuck, who found no abnormal respiratory sounds.
In order to determine if the process was of tubercular origin, the
patient was subjected to the tuberculin test, with a negative result;
TTLxv of a I per cent, solution of tuberculin was injected deep into
the thigh. X-ray of the chest was negative.
Blood Examination. Reds, 5,836,000; whites, 14,000; haemo-
globin, 65 per cent. ; urine, negative.
Operation. A preliminary tracheotomy was done, with the patient
in the sitting position. The object of doing a tracheotomy was to be
ready to inflate the lung by means of a rubber tube passed through
the tracheal opening, if necessary. Other operators have found this
expedient necessary where sudden shock was induced by collapse of
the lung.
The patient was then placed upon the operating-table, with the right
side elevated and the right arm extended over the head.
A curved incision through the skin was then made, starting in the
mid-axillary line at the fourth rib; it was then continued downward
to the infracostal edge of the ribs, thence forward to the edge of the
rectus.
A flap thus outlined was turned up from below. On dissecting
away the subcutaneous fat the growth was found to be encapsulated.
The capsule being quickly exposed, appeared greenish-black, rough
and elastic to pressure. On opening the capsule there was a gush of
blood, which continued, except when pressure with gauze was used.
(Figs. 3 and 4.)
Although many clamps were put on, the hemorrhage was still rapid.
It was evident that the tumor could not be dissected from the ribs on
account of this uncontrollable hemorrhage. By means of a large spoon
curette the entire mass was rapidly scraped away down to the ribs.
The bleeding was now partially controlled by many clamps and
pressure with gauze.
The reason for this type of hemorrhage will be seen on examination
of the pathological report. The growth we had to deal with was the
telangiectatic type of a myelogenous sarcoma. In this form of growth
the blood-supply is carried on by sinuses irregularly arranged. It was
the bleeding from these sinuses, which could not be clamped, that gave
rise to this difficulty.
On examining the exposed surface of the ribs the growth was found
496 PORTER,
to have involved the seventh, eighth, and ninth ribs, which was con-
firmed by frozen sections.
These ribs were then divided in the mid axillary line, clearing the
margin of the growth by three-fourths of an inch. On elevating the
ends of the divided ribs, the lung could be seen in a partly collapsed
condition.
The condition of sudden shock due to collapse of the lung, which
had been anticipated on account of the experiences of other operators,
did not occur. Dr. M. H. Richardson, who watched the pulse at
this stage of the operation, noticed no immediate change in the rate
or quality. There was no cyanosis or respiratory distress ; the rate
and depth of respiration, however, increased.
The intercostal muscle between the sixth and seventh ribs was next
divided with the costo-chondral ligaments and cartilage. On elevat-
ing the upper portion of the ribs thus divided the growth from the
ribs was found to have extended into the pleural cavity. The intra-
thoracic portion of the growth was cylindrical, covered by a reflection
of the parietal pleura, with its long diameter pointing downward and
inward.
The intercostal muscle, costo-chondral ligament, and cartilage of
the ninth and tenth ribs were next divided. It was now found that
the lower pole of the intrathoracic portion of the tumor was adherent
to the diaphragm. An effort was made to dissect the growth away.
This, however, could not be done without leaving a portion of the
sarcoma on the diaphragm.
The diaphragm was then cut away from the growth by an elliptical
incision, removing half an inch of normal diaphragm outside the
margin of the malignant growth. With this the ribs, tumor, and
diaphragm were removed.
On opening the diaphragm the intestines came through into the
pleural cavity. They were replaced and held back by gauze. The
opening in the diaphragm was then closed by a " shoemaker's
stitch" of animal tendon. After tying the intercostal arteries and
several other vessels the skin flap was turned down and closed with
interrupted silkworm-gut sutures. At the upper end of the incision
an opening was left, and through this a rubber tissue gauze wick was
put into the pleural cavity.
At the close of the operation the patient was sufTering considerably
from shock. The shock came on gradually, and was evidently due
to the loss of blood and not from the condition of the lung. He was
}
'T^ 60
EXCISION OF RIBS AND DIAPHRAGM FOR SARCOMA. 497
infused with 1000 c.c. of normal salt solution and stimulated. The
pulse was 160.
On recovering consciousness the patient suffered from dyspnoea,
which was much relieved by the administration of oxygen. The
oxygen was used during the first week.
The respiration was wholly thoracic. On the following morning the
patient had reacted from the shock.
On the second day respiration could be heard at the level of the
fifth rib, and on the third day at the sixth rib in the mid-axillary
line.
On the fourteenth day the chest was examined by Dr. R. C. Cabot,
who found that the right lung had reached its full expansion, and that
the respiratory sounds were normal. The wick and stitches were
removed on the tenth day, and on the eighteenth day the patient was
allowed to be up.
The patient was up and about on the twenty-first day as usual, when
he had a severe chill, followed by a temperatureof 104.5°. Nothing
abnormal was found in the chest at this time. Four days later fluid
was found in the right thoracic cavity at the level of the fourth rib, in
the mid-axillary line. Drainage was not employed, in hopes that the
exudate might absorb.
Ten days later fluid was still present, and the upper end of the in-
cision was reopened. Several ounces of a brownish straw-colored fluid,
the consistency of consomme, came out. Cultures from this fluid
showed numerous colonies presenting a variety of diplococci ; no
streptococci were present. Drainage was continued for two weeks.
From now on the convalescence was rapid. The sinus closed at the
end of two months.
Sixteen months after the operation the patient was seen. He has
gained thirty-eight pounds, and there is no evidences of recurrence of
the sarcoma. There is a marked bulging between the ribs, bordering
the resected area. This condition has been increased by the patient's
occupation, which requires him to work in the stooping position.
Pathologisfs Repoj-t. The specimen consisted of three ribs, two of
which were more or less intact, the longest measuring 13 cms. From
the middle rib there started a growth of a somewhat hour-glass shape,
consisting of a continuous extrapleural and intrapleural growth. The
opening through which the tumor mass passed measured 9 cms. in
diameter. The surface was more or less smooth, somewhat lobulated.
The two parts of the growth each measured 12.5 by 8 cms.
Am Surg 32
498 EXCISION OF RIBS AND DIAPHRAGM FOR SARCOMA.
The section surface was grayish, homogeneous, and speckled with a
few hemorrhagic and opaque necrotic areas.
Microscopical examination showed in general a round of elongated
cellular growth with a little fibrous looking intercellular substance,
through which were scattered innumerable large, multinucleated cells.
The blood seemed to circulate, generally, in spaces or cavities, but
here and there was a well-differentiated, vascular wall.
Diagnosis. Medullary (giant-celled) sarcoma, evidently originating
in the rib.
CASES OF LACERATION OF THE SPLEEN AND OF
THE KIDNEY, FOLLOWED BY RECOVERY
AFTER THE REMOVAL OF THE
INJURED ORGAN.
By SAMUEL J. MIXTER, M.D.,
BOSTON.
F, D., aged twenty-five years, a machinist by occupation, at 11.30
A.M., wliile setting up a locomotive, was struck along the left costal
border and pinned against a brick wall by one of the driving-wheels,
which fell over against him.
On examination shortly afterward, in the accident-room of the
Massachusetts General Hospital, he was found to be a well-developed
Rupture of the spleen (Mixter's case).
man; heart and lungs normal; general condition rather poor; he
had vomited once, normal stomach contents ; abdomen was very ten-
der, especially in the epigastrium, and there was dulness in both
flanks; slight abdominal rigidity; no external mark of injury save a
few bruises along the costal border. Temperature, 102.2° F. ; pulse,
104; respiration, 30.
500 MIXTER,
An incision in the median line from ensiform to three inches above
pubis showed much free blood in abdominal cavity. Liver first exam-
ined and found intact. On washing out with salt solution, a piece of
ruptured spleen was found free in the abdominal cavity. A trans-
verse incision was made to the left ; another free piece of spleen was
found, and the main body of the spleen was seen to be torn and
hanging by a few shreds of tissue, and was removed without ligation.
The splenic artery was torn and spurting, and was tied, together with
the splenic vein. Gauze was packed into abdomen in site of spleen.
During the operation a quart of salt solution was injected into a
vein in the arm. The patient's pulse fell from 130, at the end of the
operation, to 100 in the evening. The gauze packing was removed
on the fourth day, and recovery was uneventful, with the exception
of some sepsis in the external wound, due, probably, to the hurried
preparation before the operation.
Fracture of the Kidney ; Nephrectomy ; Recovery. On May 29,
1899, A. C, a slight, delicate girl, aged ten years, while crossing a
paved street, was knocked down and the wheels of a heavy express
wagon passed over her back. She was taken at once to the office of
Dr. R. W. Lovett, under whose care she had been for slight lateral
curvature. On her arrival she had almost no pulse and seemed to be
dying.
I saw her within a half-hour, when she had revived a little under
stimulation. There was no external sign of injury. The abdomen
was tender, rather more on the right than on the left, and rigid.
After a time she passed a quantity of bloody urine.
She was at once removed to a private hospital and operated upon.
The usual lumbar incision exposed an infiltrating hemorrhage into
the deep muscles and perinephritic tissues, and a rent in the peri-
toneum, through which a large quantity of blood was evacuated.
The torn kidney could be felt at the bottom of the wound, was drawn
out, and the few shreds of tissue by which it was attached were ligated
and the mass removed.
It was found that this represented little more than half the organ,
and the hand being introduced into the abdominal cavity found the
other fragment free near the stomach. This was removed, the abdo-
men washed out, and the wound partially sutured and packed with
gauze.
Recovery was uneventful, and the cliild had suffered no inconveni-
LACERATION OF THE SPLEEN AND KIDNEY. 5OI
ence since from the wound or the loss of the kidney. Her parents
report her as being much stronger during the past two years than
before the accident.
These two cases are reported as showing the extensive com-
minution of an abdominal organ that may take place without
external injury or immediate fatal hemorrhage, and the value
of early operation.
SUBTROCHANTERIC OSTEOTOMY FOR THE
DEFORMITY FOLLOWING HIP
DISEASE.
By E. H. BRADFORD, M.D.,
BOSTON.
The natural cure of hip disease, if untreated, inevitably results
in a characteristic crippling deformity, with marked flexion and
abduction. Even in the treated cases, if neglected during the
convalescent stage, this deformity frequently results.
It is not necessary to give in detail the history of the develop-
ment of the operation for the correction of the deformity, as the
facts are well known, and Gant's operation is an accepted pro-
cedure. The object of this paper is not to present what is new,
but to call the attention to some of the practical details of an
operation which is most satisfactory in its results, not difficult of
execution, but, unfortunately, not as generally employed by
the surgical profession as is desirable. The following case will
serve as a type.
A young man, aged eighteen years, suffered from hip disease when a
boy aged four years. The usual cmrse of abscesses and sinuses followed,
but after a number of years all finally healed, and he was left with a
right-angle deformity of the thigh with severe adduction. He was able
to walk with one crutch, but was unable to place the whole foot upon
the ground. There were many cicatrices of old sinuses about the hip,
subluxation, and an actual shortening of one and one-half inches.
Subtrochanteric osteotomy was performed and the limb corrected in
the manner hereafter described. The recovery was uneventful ; the
correction of the deformity has been maintained without recurrence
SUBTROCH ANTEKIC OSTEOTOMY. 5^3
for twelve years until the present time. He is now able to walk with
perfect freedom without crutch or cane, with no practical shortening
of the affected limb.
It is unnecessary to give the histories of similar cases, vary-
ing but little in detail. It may be, however, of interest to
consider the best manner of conducting the operation and
after-treatment.
The subject, for convenience, may be limited by describing
the procedure only in its application to the deformity following
hip disease ; where there is ankylosis at the hip, either osseous
or firmly fibrous, with or without subluxation, osteotomy for
coxa vara will not be considered here. There are various
methods suggested for the division of the bone, but only three
need to be mentioned : transverse osteotomy, oblique osteotomy,
and wedge-shaped section. Of these, transverse osteotomy will
be found satisfactory in the cases of flexion without adduction,
and is readily performed. In ordinary cases no preliminary
incision through the skin is necessary, as the osteotome can be
driven to the bone through the skn with a slight blow of the
mallet. The place for the entrance of the osteotome is at the
level of the lesser trochanter, or slightly below this — that is,
below the insertion of the psoas and iliacus tendons. It is
evident that where osseous ankylosis has taken place there is
little danger of recontraction whether the insertion of the ten-
don of the psoas and iliacus is below or above the break; but
even under these circumstances the point of election for the
division of the bone will be found just below the lesser tro-
chanter, on account of the greater ease of the division of the
bone at this point, narrower here than higher up on the femur.
The osteotome is driven directly to the bone through the
skin with the broad axis of the osteotome parallel with the axis
of the thigh. When the bone is reached the osteotome is
turned in the hand of the operator and driven directly through
the outer layer of the bone to the medullary layer. After the
osteotome is well engaged in the bone the direction should at
each blow be turned to the right and left, so that it will cut in
504 BRADFORD,
an excursion wider than the width of the osteotome, and to
diminish the danger of the hemorrhage. The division of the
bone is continued, working from the cortical layer to the med-
ullary layer, the difference being recognized by the difference
in the resistance to the blows of the mallet. The femur should
be divided from one-half to three-quarters of its thickness, and
the rest of the division performed by the fracture. It will be
found to be easier to fracture the remaining portion of the
femur by first moving the femur by adduction and flexion
rather than by abduction and extension, though after the bone
is fractured the limb should be moved in the direction of abduc-
tion and extension to stretch the contracted soft parts.
The width of the osteotome is a question of judgment, some
operators preferring a narrow osteotome and others a wider
one. The corners of the osteotome should be rounded to pre-
vent any sharp projection, and if carefully used the operation
is without danger of hemorrhages.
In some instances it will be necessary to perform tenotomy
or open incision of contracted tissues, but usually, especially in
children and adolescents, these tissues can be readily stretched.
It is manifestly a neater operation if the osteotome should not
be reinserted, but that all the cutting by the osteotome be per-
formed while it is still in the wound, but a reinsertion of the
osteotome can be easily made if a sufficient amount of the
bone has not been divided to make the fracture easy. It is
manifestly an advantage to leave a certain amount of the bone
uncut to be fractured, as the uncut periosteum helps in the
needed subsequent union of the fragments.
Oblique Osteotomy. In place of transverse osteotomy the
bone may be divided obliquely, entering the osteotome slightly
below the greater trochanter, directed to below the lesser tro-
chanter, from without inward and from above downward. This
is advised for the purpose of increasing the length of the limb,
employing forcible traction for the purpose at the time of the
operation or during after-treatment. The amount of lengthen-
ing gained in this way is, however, limited by the fascia and
shortened muscles, which can be stretched, and by the lack of
SUBTROCHANTERIC OSTEOTOMY. 505
elasticity of the uncut periosteum. If the periosteum were
entirely severed, firm union is apt to be delayed or interfered
with, a complication to be avoided.
Oblique osteotomy has, over linear osteotomy, the advantage
of furnishing in the obliquity of the fragment an obstacle to
the slipping inward of the lower fragment if the limb is thor-
oughly abducted. Experience enables the surgeon to determine
by the sense of touch the correct position of the edge of the
instrument, and with ordinary care there is no danger of hem-
orrhage or undue injury to the adjacent tissues. Wedge-shaped
resection of the femur near the trochanter has no practical ad-
vantage over oblique osteotomy, and, though mechanically cor-
rect, is surgically unnecessary.
Position of the Osteotomized Limb. In cases with adduction,
or when there is much subluxation, oblique osteotomy is pre-
ferable to linear, but after either has been performed the question
of the position in which the limb is to be placed is of the great-
est importance, as the success of the operation naturally depends
upon the position in which the fragments of the bone are placed
for reunion. If the periosteum is but little injured, it is well
known that union of broken bones takes place finally, even if
the axis of the fragment differs greatly from that of the original
bone.
Nature's fault in the union of neglected fractures serves as
a precedent in the correction of the deformity. In the simplest
cases the contractions of the soft parts are readily overcome
after the osteotomy by manual effort. If the deformity is not
great, and that chiefly of flexion without much actual shorten-
ing, all that is necessary is to place the limb in a position nearly
parallel to the normal bone, and allow union to take place. If
flexion is severe the fragments do not remain in contact after
correction, in their whole cut surface, but this in no way pre-
vents a firm union with the upper or lower fragments, forming
an angle instead of a straight line, the callus giving sufficient
solidity for future use.
Whether the limb is to be placed in a position in a plane
with the long axis of the trunk, or slightly flexed, will depend
5o6 BRADFORD,
upon the amount of flexibility in the lumbar spinal column.
If the latter is rigid the patient will find difficulty subsequently
in sitting comfortably if the flexion is completely corrected.
Ordinarily, however, especially in adolescents and children, an
exaggerated amount of flexibility has been developed in cases of
this sort, and this can be relied upon to give sufficient amount
of change in the position of the thigh relative to the axis of the
trunk for the different positions incident to sitting, standing,
and walking. To avoid the danger of this it is, however, de-
sirable in older patients to place the thigh in a position of
slight flexion ; not more than fifteen degrees will be required
for this. Where the limb is adducted as well as flexed it is
necessary to place the limb in an abducted as well as a straight-
ened position, the amount of the abduction depending upon
circumstances, especially the amount of actual shortening of
the limb. It is to be borne in mind that in cases of severe
distortion after hip disease, with flexion and adduction, tilting
of the pelvis takes place, the affected side being abnormally
raised. This adds a practical shortening of the limb, measur-
ing from the umbilicus to that given by the flexion of the limb,
and to the actual shortening from subluxation. If this abnor-
mal tilting of the pelvis is corrected the practical shortening is
diminished, and if this tilting of the pelvis is over-corrected, so
that the pelvis is tilted in the direction opposite to its former
position, a practical lengthening can be secured. The amount
of this practical lengthening depends upon the amount of pos-
sible tilting of the pelvis in the corrected direction. This,
again, is dependent upon the lateral flexibility of the spinal
column. In adolescent cases a practical lengthening of from
two to three inches can be frequently secured in this way, which
is frequently enough to overcome the shortening from subluxa-
tion and also from arrest of growth unless this is unusually great.
The operation, if done without preliminary incision down to
the bone, is practically a subcutaneous one, and the dressing
required is small if proper aseptic precautions are observed. It
is usually unnecessary to disturb the wound until several weeks
after the operation.
SUBTROCHANTERIC OSTEOTOMY. 5O7
In selecting the means of fixing the limb after osteotomy, the
decision is influenced by the ease with which the correction
has been obtained. Where there are few contractions of the
soft part and the fractured limb can be placed easily in the
desired position, it will be found most serviceable to place the
patient in a plaster-of-Paris spica with the affected limb strongly
abducted, if the previous adduction has been great. The sink-
ing of the mattress at the buttock is usually sufficient to allow
for a slight amount of flexion, which is ordinarily desirable.
The advantage in a plaster-of-Paris bandage consists in the fact
that the patient is placed in a position that he cannot escape
from. There is less danger of the misplacement of the frag-
ments in changing the patient's position. The disadvantages
of plaster-of-Paris bandages lie in the discomfort caused if im-
perfectly applied and in the fact that the position of the limbs
cannot be readily changed. Where complete correction is not
possible, and it is desirable to stretch the contraction of the soft
parts, a traction appliance can be used, the ordinary weight of
the pulley being the most convenient.
The amount of abduction to be given the limb varies with
the amount of practical lengthening desired. An abduction of
forty-five degrees will be found not excessive in cases of severe
distortion, and will be of advantage in securing practical
lengthening.
It is evident that where the limb is placed in an over-
corrected position after severe deformity, it will be necessary
to allow considerable time before expecting complete solidifica-
tion, and under these conditions some retentive apparatus is
advisable. Plaster-of-Paris furnishes a suitable support for this
purpose, but as a substitute a stiffened leather splint laced upon
the trunk and thigh will answer. It is not safe ordinarily to
allow the patient to bear any weight upon the limb until ten weeks
after the operation, and in larger patients where the deformity
is great three months of protection is preferred. Locomotion
by aid of crutches should be permitted after eight weeks.
It is evident that where the ossification is not rapid, danger
of relapse exists. This should be prevented by obliging the
508 SUBTROCHANTERIC OSTEOTOMY.
patient to wear retentive apparatus for a long period, even after
locomotion with crutches is allowed. The amount of time that
is necessary for retentive treatment depends upon conditions
not easily defined, and is a matter of judgment.
It is desirable that the operation should not be done on too
young or on rapidly growing patients. The yielding character
of growing bone, and its inability to resist deforming pressure
in sitting and standing may cause a recurrence of the deformity,
a danger which does not exist in older patients. An unusual
complication may be mentioned — namely, the coexistence of
severe knock-knee, with severe adduction and flexion of the
thigh, following hip disease, requiring after the operation at
the hip a second osteotomy at the knee, but with a successful
result in the end.
In fine, the operation may be considered as most satisfactory
to both patient and surgeon, correcting the deformity and
diminishing a humiliating disability, with but little discomfort
to the patient and no greater risk than that following a fracture.
The demand upon the surgeon consists simply in the exercise
of skill and judgment easily acquired.
IN DEX.
Abdominal operations, phlebitis following, 223
Abscess of lung, pneumotomy for, 482
Address of the President, Park, i
Allis, fractures of the pelvis from violence exerted through the long axis of
the femurs, being a comparative study of the relative strength of the neck
of the femur and that of the pelvis when the violence is transmitted
through the long axis of the former, 145
Anaesthetic, ether as an, 72
Aneurisms, aortic, treatment of, by means of silver wire and electricity, 359
traumatic arterio-venous, of subclavian vessels, 237, 286
Apparatus for artificial respiration in surgical and medical practice, 410
for massive infiltration anaesthesia with weak analgesic solutions, 412
Appendicitis, clinical value of blood examinations in, 60
Arthrotomy in treatment of anterior dislocation of tibia, 441
Artificial respiration by direct intralaryngeal intubation with a modified
O'Dwyer tube and a new graduated air-pump in its applications
to medical and surgical practice, 392
use of Fell's apparatus for, 383
Automatic respiratory apparatus, 408
Bevan, discussion on prevention and cure of post-operative hernia, 312
on traumatic arterio-venous aneurisms of the subclavian vessels,
292, 294
Blake, studies of the blood in its relation to surgical diagnosis, 104
Blood changes induced by the administration of ether as an anaesthetic, 72
examination of, in relation to surgery, 115
examinations as an aid to surgical diagnosis, 122
clinical value of, in appendicitis, 60
studies of the, in its relation to surgical diagnosis, 104
Bloodgood, blood examinations as an aid to surgical diagnosis, 122
Bradford, subtrochanteric osteotomy for the deformity following hip disease,
502
Breast, cancer of, treated at the Johns Hopkins Hospital since 1899, 26
removal of, new method of closing the wound in thorough removal of
380
5IO INDEX.
Brewer, discussion on pancreatitis, 172
Bryant, influence of mental depression on the development of malignant
disease, 43
Cabot, studies of the blood in its relation to surgical diagnosis, 104
Calculus, double renal, 377
Cancer of breast, cases of, treated at the Johns Hopkins Hospital since
1899, 26
cause of, 57
recent Buffalo investigations regarding the nature of, i, 59
Carcinoma of uterus, early signs of, 24
Carmalt, discussion on thorough removal of breast, 382
Carson, discussion on pancreatitis, 180
Catheterization of ureters in the male, 218
Cicatricial stricture of the oesophagus, 450
Chnical value of blood examinations in appendicitis, 60
Coley, discussion on operation for the radical cure of umbihcal hernia, 305
late results of the treatment of inoperable sarcoma with the mixed
toxins of erysipelas and bacillus prodigiosus, 27
radical cure of inguinal and femoral hernia, 337, 358
Cullen, cause of cancer, 57
early signs of carcinoma of the uterus, 24
Curtis, discussion on examination of the blood in relation to surgery, 143
Da Costa, John Chalmers, blood changes induced by the administration
of ether as an anaesthetic, 72
Da Costa, J. C, Jr., clinical value of blood examinations in appendicitis, 60
Deaver, examination of the blood in relation to surgery of scientific but
often of no practical value, and may misguide the surgeon, 115
Elliot, discussion on pancreatitis, 178
Estes, discussion on pancreatitis, 181
Ether as an anaesthetic, 72
Excision of a part of three ribs and a portion of the diaphragm for sarcoma,
494
Exhibition of methods of medical instruction in the Johns Hopkins Medical
School and Hospital, 216
Fell's apparatus for artificial respiration, use of, 383
Finney, discussion on double renal calculus, 379
on treatment of aortic aneurisms by means of silver wire and elec-
tricity. 373
Fowler, discussion on pancreatitis, 179
on phlebitis following abdominal operations, 234
INDEX. 511
Fractures and dislocations of spine, 314
of pelvis, 145
Freeman, discussion on pancreatitis, 182
treatment of aortic aneurisms by means of silver wire and electricity,
359. 375
Gastro- ENTEROSTOMY, vicious circle after, 417
Gastrostomy with retrograde dilatation of stricture by rubber tubes, 450 ,
Gerrish, discussion on operation for the radical cure of umbilical hernia, 304
Giant sacrococcygeal tumors, 444
Halsted, brief consideration of cases of cancer of the breast treated at the
Johns Hopkins Hospital since 1899, 26
discussion on radical cure of inguinal and femoral hernia, 357
on traumatic arterio-venous aneurisms of the subclavian vessels,
-93
Harris, movable kidney, its cause and treatment, 457
Harte, discussion on fractures and dislocations of spine, 335
Hearn, pneumotomy for abscess of lung, 482
Hernia, inguinal aiid femoral, radical cure of, 337
post- operative, prevention and cure of, 307
umbilical, operation for the radical cure of, 296
Hip disease, subtrochanteric osteotomy for the deformity following, 502
Hubbard, studies of the blood in its relation to surgical diagnosis, 104
Infiltration anaesthesia, apparatus for, 412
Inguinal and femoral hernia, radical cure of, 337
Inoperable sarcoma, treatment of, with the mixed toxins of erysipelas and
bacillus prodigiosus, 27
Johns Hopkins Medical School and Hospital, methods of medical instruc-
tion in, 216
Kalteyer, blood changes induced by the administration of ether as an
anaesthetic, 72
Keen, resection of a large part of the chest wall for a sarcoma ; use of Fell's
apparatus for artificial respiration ; late continuous fever due to staphylo-
coccus blood infection ; successful use of the antistreptococcic serum ;
complete recovery, 3S3
Kelly, necessity of employing the newer methods of diagnosis in rectal and
urinary diseases, 216
Kidney, laceration of, 499
movable, its cause and treatment, 457
Laboratory methods of teaching, 219
Laceration of spleen and kidney, 499
512 INDEX.
Lange, discussion on phlebitis following abdominal operations, 236
Lung, abscess of, pneumotomy for, 482
McCoSH, discussion on operation for the radical cure of umbilical hernia,
305
McGraw, discussion on traumatic arterio-venous aneurisms of the subclavian
vessels, 294
two cases of vicious circle after gastro-enterostomy, 417
Mahgnant disease, influence of mental depression on the development of, 43
Matas, an apparatus for massive infiltration anaesthesia with weak analgesic
solutions (modified Schleich method), 412
artificial respiration by direct intralaryngeal intubation with a modified
O'Dwyer tube and a new graduated air-pump in its applications to
medical and surgical practice, 392
discussion on treatment of aortic aneurisms by means of silver wire and
electricity, 374
traumatic arterio-venous aneurisms of the subclavian vessels, 237, 286,
294
Mayo, discussion on phlebitis following abdominal operations, 235
on surgical treatment of chronic ulcer of the stomach, 213
operation for the radical cure of umbilical hernia, 296, 306
Mental depression, influence of, on the development of malignant disease, 43
Method, new, of closing the wound in thorough removal of breast, 380
Mixter, cases of laceration of spleen and of kidney, 499
discussion on fractures and dislocations of spine, 335
double renal calculus, 377
new method of closing the wound in thorough removal of breast, 380
Moore, prevention and cure of post-operative hernia, 307, 313
Movable kidney, its cause and treatment, 457
Munro, discussion on fractures and dislocations of spine, 333
Necessity of employing the newer methods of diagnosis in rectal and
urinary diseases, 216
OCHSNER, discussion on operation for the radical cure of umbilical hernia,
301
CEsophagus, cicatricial stricture of, 450
Operation for the radical cure of umbilical hernia, 296
Opie, discussion on pancreatitis, 176
Osteotomy, subtrochanteric, 502
Pancreatitis, 149
Park, the recent Buffalo investigations regarding the nature of cancer, i, 59
Pelvis, fractures of, 145
INDEX. 513
Phlebitis following abdominal operations, 223
Pontico, discussion on fractures and dislocations of spine, 335
Porter, excision of a part of three ribs and a portion of the diaphragm for
sarcoma, 494
Post-operative hernia, prevention and cure of, 307
Powers, giant sacrococcygeal tumors, 444
P;esident's address, Park, i
Prevention and cure of post-operative hernia, 307
Radical cure of inguinal and femoral hernia, 337
Recent Buffalo investigations regarding the nature of cancer, i, 59
Rectal and urinary diseases, necessity of employing the newer methods in,
216
Renal calculus, double, 377
Resection of a large part of the chest wall for a sarcoma, 383
Roberts, anterior dislocation of tibia treated by arthrotomy, 441
Robson, pancreatitis, 149, 182
surgical treatment of chronic ulcer of the stomach, 184, 215
Redman, discussion on surgical treatment of chronic ulcer of stomach,
214
Roe, pneumotomy for abscess of lung, 482
Sacrococcygeal tumors, 444
Sarcoma, inoperable, treatment of, 27
resection of a large part of the chest wall for a, 383
Schleich method, modified. 412
Silver wire and electricity in treatment of aortic aneurisms, 359
Spine, fractures and dislocations of, 314
Spleen, laceration of, 499
Stomach, ulcer of, surgical treatment of, 184
Stricture, cicatricial, of cEsophagus, 450
Studies of the blood in its relation to surgical diagnosis, 104
Subtrochanteric osteotomy for the deformity following hip disease, 502
Surgical treatment of chronic ulcer of the stomach, 184
Tibia, anterior dislocation of, treated by arthrotomy, 441
Traumatic arterio-venous aneurisms of the subclavian vessels, 237, 286
Tumors, giant sacrococcygeal, 444
Turner, discussion on phlebitis following abdominal operations, 235
Ulcer of stomach, chronic, surgical treatment of, 184
Umbilical hernia, operation for the radical cure of, 296
Ureters, catheterization of, 219
Uterus, carcinoma of, early signs of, 24
Am Surg :?3
514 INDEX.
Vaxder Veer, phlebitis following abdominal operations, 223, 235
Vicious circle after gastro-enterostomy, 417
Warren, discussion on operation for the radical cure of umbilical hernia.
306
on radical cure of inguinal and femoral hernia, 356
on thorough removal of breast, 382
Weeks, fractures and dislocations of spine, 314, 336
Welch, laboratory methods of teaching, 219
Wharton, cicatricial stricture of the oesophagus, 450
Willard, discussion on operation for the radical cure of umbilical hernia, 304
on treatment of aortic aneurisms by means of silver wire and elec-
tricity, 374
Young, catheterization of ureters in the male, 218
*
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